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THE   OPERATIONS   OF   SURGERY 


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THE 


OPERATIONS  OF  SURGERY 

INTENDED   ESPECIALLY   FOR   THE   USE   OF 

THOSE   RECENTLY   APPOINTED 

ON  A   HOSPITAL   STAFF 

AND   FOR 

THOSE  PREPARING  FOR  THE  HIGHER  EXAMINATIONS 


W.    H.    A.    JACOBSON 

M.CH.  OXON.,  F.R.C.S. 

SURGEON      guy's      HOSPITAL 


R    J.    STEWARD 

M.S.  LONDON,  F.R.C.S. 

ASSISTANT    SURGEON    GUY'S    HOSPITAL 

AND   THE    HOSPITAL   FOR    SICK   CHILDREN,    GREAT  ORMOND    STREET 

SURGEON     IN     CHARGE     OF    THE    THROAT     DEPARTMENT,     GUY'S     HOSPITAL 


FOURTH   EDITION 


WITH    FIVE    HUNDRED    AND    FIFTY    ILLUSTRATIONS 


VOL.  II 


PHILADELPHIA 

P.    BLAKISTON'S    SON    &    CO. 

1012    WALNUT    STREET 
1902 


QxU^^^ 


PARDON  AND  SONS,  PRINTERS 
WINE  OFFICE  COURT,  FLEET  STREET 


IfoZ 
»/,  2. 


CONTENTS  OF  VOLUME  II. 


PART  IV. 
OPERATIONS  ON  THE  ABDOMEN. 

CHAP.  PAGE 

I.  Ligature  of  Vessels. — External  iliac. — Common   iliac— Internal 

iliac. — Gluteal. — Sciatic. — Abdominal  aorta  .....         1-32 

II.  Operatioxs    on^    Herxia. — Operations   for   strani^iilated    hernia. — 

Radical  cure  of  hernia  ........       33-84 

III.  CoLOTOMY. — Lumbar  or  posterior  colotomy. — Inguinal,  iliac,  or  an- 
terior colotomy. — Eight  inguinal  colotomy.^Making  an  artificial 
anus  in  the  ciecum. — Making  an  artificial  anus  in  the  transverse 
colon      ,         .         .         .         .         .         .         .         .         .         .         .85-112 

IV.  Operatioxs  ox  the  Kidxey  axd  Ureter. — Nephrotomy. — Nephro- 
lithotomy.— Nephrectomy. — -Nephrorraphy. — Operations  on  the 
ureter 113  172 

V.  Operatioxs  ox  the  Ix'testixes. — Acute  intestinal  obstruction. — 
Appendicitis. — Perforation  of  gastric  ulcer. — Perforation  of  duo- 
denal ulcer. — Perforation  of  tyi^hoid  ulcer. — Abdominal  section  in 
peritonitis. — -Enterostomy. — Formation  of  an  artificial  anus  in  the 
small  and  large  intestine. — Union  of  divided  or  injured  intestine 
by  suture  or  otherwise. — Modifications  of  circular  enterorraphy. — 
Aids  to  its  performance,  or  means  of  replacing  it.^Resection  of 
intestine.— Enterectomy. — Colectomy. — Intestinal  anastomosis. — 
Short  circuiting. — Lateral  anastomosis. — Closure  of  ffccal  fistula 

or  artificial  anus. — Enteroplasty 173  280 

VI.  Operative   Ixterferexce   ix   Gl-xshot   axd  other  Ix.ti'ries  of 

THE  Abdomex. — Rupture  of  the  Ixtestixe        ....  281-295 

VII.  Operatioxs  ox  the  Stomach. — ^Gastrostomy. — Gastrotomy. — Digital 
dilatation  of  the  orifices  of  tlie  stomach. — Pyloroplasty. — Pylorec- 
tomy. — Excision  of  the  pylorus. — Gastrectomy. ^Gastro-jejunos- 
tomy. — ^Gastroplication  — Duodenostomy. — Jejunostomy        .         .  296-341 

VIII.  E.xcisiox  OF  the  Spi.eex 342-345 


vi  CONTENTS  OF  VOLUME  IT. 

CHAP.  PAGE 

IX.  Operations  on  the  Liver  and  Biliary  Tracts. — Operations  for 
hydatids. — Hepatic  abscess. — -Hepatotomy. — Removal  of  portions 
of  the  liver  for  new  growths. — Operations  on  the  biliarj^  tracts  : 
Cholecystostomy. —  Cholecystotomy.  —  Cholelithotrity. —  Choledo- 
chotomy.— Cholecystenterostomy. — Cholecystectomy. — -Treatment 

of  biliary  fistula 346-369 

X.  Operations  on  the  Pancreas. — Treatment  of  pancreatic  cysts. — 

Acute  pancreatitis 370-374 

XL  Operations  on  the  Bladder. — Removal  of  growths  of  the  bladder. 
— Operative  interference  in  tubercular  disease  of  the  bladder. — 
Partial  prostatectomy. — Lateral  lithotomy. — Supra-pubic  litho- 
tomy.— Median  lithotomy. — Lithotrity. — Litholapaxy. — Perinseal 
lithotrity. — Litholapaxy  in  male  children. — Treatment  of  stone 
in  the   bladder  in   the   female. — Cystotomy. — Ruptured  bladder. 

— Puncture  of  the  bladder 375-434 

XII.  Operations,  on  the  Urethra  and  Penis. — Ruptured  urethra. — 
External  urethrotomy. — Choice  of  an  operation  for  the  relief  of 
stricture-retention. — Internal  urethrotomy. — -Ectopia  vesicae  and 
epispadias. — Hypospadias. — Epispadias. — Circumcision.  —  Ampu- 
tation of  the  penis .         .         .         .         .         .         .         .         .         .  435  46 

XIII.  Operations   on    the   Scrotum    and    Te,sticle. — Radical    cure    of 

hydrocele. — Varicocele. — Castration. — Orchidopexy. — Vasectomy.  464-486 

XIV.  Operations  on  the  Anus  and  Rectum. — Fistula, — ^Hjemorrhoids. 

— Fissure. — Ulcer.— Prolapsus. — Excision    of    the    rectum. — Im- 
perforate anus. — Atresia  ani. — Imperfectly  developed  rectum        .  487-520 

XV.  Ruptured  Perineum 521-525 

XVI.  Operations    on    the    Ovary.  —  Ovariotomy. — Removal    of    the 

uterine  appendages         .........  526-549 

XVII.  Operations  on  the  Uterus. — Removal  of  the  myomatous  uterus 
by  abdominal  section. — Cancer  of  the  uterus. — 'Removal  of  a 
cancerous  uterus  by  abdominal  section. — Removal  of  a  can- 
cerous uterus  per  vaginam.— Caesarian  section. — Porro's  operation. 
• — Ectopic  gestation        .         .         .         .         .         .         .         .         .  550-576 

XVIII.  Sacro-iliac  Disease. — Arthrectomy 577 


PART  V. 
OPERATIONS  ON  THE  LOWER  EXTREMITY. 

I.  Operations   on  the   Hip-Joint. — Amputation  at  the  hip-joint. — 

Excision  of  the  hip 578-602 

II.  Operative  Interference  in  Dlslocation  of  the  Hip        .         .  603-606 


CONTEXTS  OF  \'OLUME  II.  vii 

CHAP.  p^GE 

III.  Operations  ox  the   Thigh. — Ligature  of  the  common  femoral. — 

Ligature  of  the  superficial  femoral  in  Scarpa's  triangle. — Ligature 
of  the  femoral  in  Hunters  canal. — Punctured  and  stab  wound 
in  mid-thigh.  —  Amputation  through  the  thigh.  — Amputation 
immediately  above  the  knee-joint. — Removal  of  exostosis  from 
near  the  adductor  tubercle. — Ununited  fracture  of  the  femur    .   607-631 

IV.  Operations    involving   the   Knee-Joint.  —  Amputation  through 

the  knee-joint. — Excision  of  the  knee-joint. — Arthrectomy  of  the 
knee-joint. — Wiring   the  patella.  —  Eemoval  of  loose  cartilages 
from  the  knee-joint. — Slipped  fibro-cartilages         ....  632-659 
V.  Operations    on   the   Popliteal   Space. — Ligature  of  the  popli- 
teal artery      660-662 

v  VI.  Operations  on  the  Leg. — Ligature  of  ti)e  posterior  tibial  artery. 
—  Ligature  of  the  anterior  tibial  artery.  —  Ligature  of  the 
peroniBal  artery,  —  Amputation  of  the  leg.  —  Operation  for 
necrosis. — Treatment  of  compound  fractures. — Operation  for  simple 
fracture. — Excision  of  varicose  veins       ......  663-686 

VII.  Operations  on  the  Foot.  —  Ligature  of  the  dorsalis  pedis.  — 
Syme's  amputation. — Roux's  amputation. — Pirogoffs  amputation. 
— Sub-astragaloid  amputation. — Excision  of  the  ankle. — Era.sion 
of  the  ankle. — Excision  of  bones  and  joints  of  the  tarsus. — Excision 
of  the  astragalus. — Excision  of  the  os  calcis. — More  complete 
tarsectomy  for  caries. — Removal  of  wedge  of  bone  and  other  ope- 
rations for  inveterate  talipes. — Chopart's  amputation. — Tripiers 
amputation.  —  Amputation    through    the    metatarso  -  phalangeal 

joints. — Amputation  of  the  toes 687-721 

VIII.  Osteotomy. — Of  the  femur,  for  ankylosis  of  the  hip-joint. — For  ^'enu 

valgum. — Of  the  tibia    .........  722-720 

IX.  Tenotomt. — Of    the   tendons    about    the   foot. — Syndesmotomy. — 

Of  the  hamstring  tendons. — Of  the  sterno-mastoid         .         .         .  730-734 
X.  Operations  on  the  Nerves. — Nerve  suture. — Nerve  stretching     .  735-741 


PART    VI. 

OPERATIONS  ON  THE  VERTEBRAL  COLUMN. 

Spina   bifida.  —  Laminectomy.  —  Rachiotomy.  —  Partial    resection    of    the 

vertebrae. — Tapping  the  spinal  theca 742-754 


PART    lY. 

THE    ABDOMEN. 

CHAPTER    I. 
LIGATURE    OF    VESSELS. 

EXTERNAL    ILIAC.      COMMON    ILIAC.      INTERNAL    ILIAC. 
GLUTEAL.      SCIATIC.      ABDOMINAL  AORTA. 

LIGATURE  OF  THE  EXTERNAL   ILIAC  (Figs.  I,  2,  and  3). 

Indications. — Cliiefly : 

I.  Some  cases  of  aneiiiysm  of  the  upper  part  of  the  femoral,  or  of  the 
femoral  encroaching  on  the  external  iliac  itself. — Mr.  Holmes  (R.C.S. 
Lect.,  Lancet,  1873,  vol.  i.)  shows  that  in  ilio-femoral  anenrysms  it  is 
often  very  difficult  to  say  whether  the  aneurysm  is  or  is  not  limited  to 
the  iliac  or  femoral — i.e.,  whether  it  is  wholly  above  or  below  the  place 
where  the  deep  epigastric  and  circumflex  iliac  come  off,  or  whether  the 
mouths  of  these  vessels  open  out  of  the  sac.  In  the  former  case  the 
aneurysm  would  be  purely  iliac  or  femoral ;  in  the  latter,  ilio-femoral. 
Thus,  ligature  of  this  vessel  is  indicated  where  pressure,  rapid  or 
gradual,  has  failed  to  command  the  circulation,  where  it  is  intolerable, 
where  it  cannot  be  made  use  of  owing  to  the  abundance  of  fat.  froui 
failure  of  pulse  and  breathing  under  an  anaesthetic,  or  from  the  height 
at  which  the  aneurj'sm  involves  the  external  iliac  (it  being  increasingly 
difficult  to  apply  pressure  in  these  cases  without  dangerous  interference 
with  the  peritoneum  and  its  contents),  where  the  patient  from  chronic 
bronchitis  is  quite  unfit  for  a  prolonged  trial  of  continuous  pressure 
under  an  anaesthetic,  or  in  cases  where  the  increase  of  the  aneurysm  is 
very  rapid. 

Before  deciding  on  relinquishing  the  idea  of  pressure  for  ligature,  the 
surgeon  should  refer  to  a  paper  by  Mr.  Wheelliouse  (Clin.  Soc.  Trans., 
vol.  vii.  p.  57).     This  case  is  one  of  the  most  interesting  in  all  surgery. 

The  patient,  a  publican,  and  syphilitic,  had  previously  been  cured  by  ilr.  'Wheelliouse 
VOL.  II.  1 


2  OPERATIOXS  OX  THE  ABDOMEX. 

of  a  right-sided  popliteal  aneurysm.*  by  means  of  continuous  pressure  for  eight  hours 
with  a  Porter's  femoral-compressor.  A  few  months  later  he  was  admitted  into  the 
Leeds  Infirmary  with  a  large  right  iliac  aneurysm,!  reaching  from  Poupart's  ligament 
to  within  two  inches  of  the  umbilicus,  and  extending  outwards  almost  to  the  spine  of 
the  ilium.  The  swelling,  about  the  size  of  a  small  cocoa-nut,  was  hard  and  firm  below, 
soft  above ;  it  appeared  to  be  wholly  connected  with  the  external  iliac,  but  to  extend 
above  and  overlie  the  common  iliac.  Pressure  could  not  be  made  on  the  latter  vessel 
sufficient  to  stop  the  beating,  as  the  tumour  was  too  much  in  the  way,  but  it  was  easily 
controlled  by  pressure  on  the  abdominal  aorta.  The  patient  was  kept  under  the  influence 
of  ether  for  five  hours,  Listers  tourniquet  being  very  slowly  screwed  down  just  over  the 
umbilicus.  By  the  end  of  the  time  the  patient  was  black  in  both  limbs,  and  blue  as  far 
as  the  tourniquet.  This  had  been  slightly  relaxed  twice.  No  other  unpleasant  symptom 
arose  during  the  whole  time.  A  quarter  of  an  hour  was  taken  in  relaxing  the  pressure 
— a  quarter  turn  of  the  handle  being  made  every  minute.  The  tumour  had  ceased  to 
pulsate,  and  was  firm  and  hard.  Pulsation  gradually  recurred  with  nearly  its  old  force, 
but  was  less  "  disteusile,"  and  slowly  ceased  altogether,  an  excellent  recovery  being 
made.J 

111  riiptitred  femoral  aneurysm  the  old  operation  (facilitated  by  the 
application  of  a  tourniquet  above)  would  usually  be  indicated,  but  Mr. 
Southam  (Brit.  Med.  Journ.,  1 883,  vol.  i.  p.  818)  has  briefly  reported  a 
case  in  which  he  tied  the  external  iliac  successfully  in  a  patient  whose 
femoral  aneurysm  suddenly  ruptured  and  became  diffuse.      The  effused 

*  It  is  very  possible  that  the  strain  thrown  on  the  artery  above  during  the  treatment 
by  pressure  on  the  femoral  was  the  cause  of  the  aneurysm  higher  up.  The  liability  of 
patients  with  one  aneurj^sm  to  develop  another  may  often  baffle  the  surgeon.  Mr. 
Clutton  (^Brit.  Med.  Journ..  1880,  vol.  i.  p.  441)  records  a  case  in  which  a  femoral 
aneurysm  was  cured  by  the  use  of  Esmarch's  bandage  applied  up  to  the  tumour,  and  a 
Petit's  tourniquet  adjusted  over  the  brim  of  the  pelvis.  The  first  attempt  lasted  an 
hour;  at  the  second  trial  the  bandage  was  removed  in  an  hour,  and  the  tourniquet  con- 
tinued for  nine  hours,  ansesthetics  not  being  given.  The  aneurysm  ceased  to  pulsate 
and  began  to  shrink,  but  still  fluctuated.  Nine  days  after  leaving  the  hospital,  the 
patient  died  suddenly  of  an  aortic  aneurysm  rupturing  into  the  pericardium. 

f  Dr.  Diver,  of  Southsea,  has  put  on  record  a  case  in  which  the  external  iliac  was  tied 
in  a  case  in  which  a  popliteal  and  an  inguinal  aneurysm  co-existed  on  the  right  side. 
Gangrene  followed,  a  line  of  demarcation  forming  in  the  lower  third  of  the  leg. 
Amputation  through  the  thigh  was  performed,  and  the  patient  recovered.  A  similar 
case  of  double  aneurysm  is  reported  by  Mr.  Hilton  {Med.-Ckir.  Trans.,  vol.  lii.  p.  309). 
A  tourniquet  was  first  applied  to  the  right  common  iliac  for  six  hours  withoitt  effect  on 
the  aneurysms.  A  second  trial  of  pressure  was  made  later  on,  with  a  tourniquet 
again  on  the  common  iliac  and  one  on  the  femoral  at  the  apex  of  Scarpa's  triangle. 
In  abotit  nine  hours  both  aneurysms  were  cured.  Chloroform  was  used  on  both 
occasions. 

X  Cases  of  Dr.  Mapother's  and  Mr.  Holden's,  in  which  ilio-femoral  aneurysms  were 
cured  by  pressure  on  the  common  iliac  and  the  aorta,  will  be  found  recorded  by  Dr. 
Mapother  in  the  Dub.  Med.  Press,  March  29,  1865 ;  and  by  Mr.  Holden  in  ,S'^.  Barthol. 
Uosj).  Bep.,  vol.  ii.  p.  190 ;  Syd.  !^oc.  B'len.  Retr.,  1865-6,  pp.  306,  307.  In  Dr.  Mapothers 
case,  instrumental  pressure  on  the  right  common  iliac  (about  an  inch  below  and  half 
an  inch  to  the  right  side  of  the  umbilicus),  kept  up  for  twelve  hours  under  chloroform, 
had  failed.  A  second  attempt,  with  a  Signorini's  tourniquet  on  the  end  of  the  abdominal 
aorta,  and  a  Skey's  tourniquet  on  the  femoral  just  as  it  left  the  sac,  pressure  being  kept 
up  for  four  hours  and  a  half,  made  the  tumour  solid  and  pulseless.  Two  rigors  followed, 
and  a  carbuncle  formed  at  the  site  of  the  first  compression.  In  Mr.  Holden's  patient 
the  aneurj'sm  was  also  large,  and  double  aortic  valvular  disease  was  present.  Chloroform 
was  given  here  continuously  for  an  hour  and  a  half,  and  then  with  cautious  intermis- 
.sions,  owing  to  the  state  of  the  pulse  and  breathing,  for  the  rest  of  the  treatment,  which 
lasted  four  hours. 


LIGATURE  OF  THE  EXTEEXAL  ILIAC.  3 

blood  was  quickly  absorbed,  and  there  was  never  any  tendency  to  gan- 
grene.    Comjjlete  power  over  the  limlj  was  regained. 

2.  Wounds. — A  wound  of  the  external  iliac  is  so  rare  as  to  be  almost 
Tinknown.*  It  has  been  frequently  tied  for  hasmorrhage  from  parts 
below — e.f/.,  for  secondary-  haemorrhage  after  wounds  of  the  femoral  high 
up,  after  ligature  of  the  femoral,  and  after  amputation  at  or  near  tlie 
hip.     The  futilityf  of  this  treatment  is  thus  shown: 

Dr.  Otis  QMed.  and  Surg.  History  of  the  War  of  the  Rebellion,  pt.  iii.  p.  788)  gives  a 
.summary  of  twenty-six  cases  in  which  the  external  iliac  was  tied  for  such  cases  as  the 
above.  Of  these,  twenty-three  ended  fatally,  a  mortality  of  88-4  per  cent.  The  useless- 
ness  of  trusting  to  ligature  of  the  external  iliac  in  such  cases,  instead  of  either  securing 
the  wounded  vessel  itself,  or  trusting  to  well-applied  pressure,  was  long  before  this 
insisted  on  by  Guthrie.;}:  This  question  is  alluded  to  again  below,  but  in  proof  of  the 
above  statement  a  case  may  be  mentioned  here,  in  which  hieraorrhage  returned  after 
ligature  of  the  external  iliac,  and  was  arrested  by  well-applied  pressure.  The  patient 
had  been  wounded,  January  15,  1865,  by  a  minie  ball,  entering  at  the  upper  and  inner 
part  of  the  thigh,  and  emerging  near  the  knee.  The  wound  becoming  sloughy,  haemor- 
rhage occurred  (March  23  and  31),  and  the  external  iliac  was  tied.  April  21,  haemorrhage 
recurred  from  the  upper  gunshot  wound,  and  was  successfully  restrained  by  a  horseshoe 
tourniquet,  constantly  kept  on  for  two  weeks,  when  it  was  omitted,  without  any  sub- 
sequent hemorrhage.  The  wounds  were  now  healing  kindly,  when  (May  31)  dysentery 
set  in,  carrying  off  the  patient,  .June  15,  two  and  a  half  months  after  the  operation  of 
ligature. 

3.  Elephantiasis. — Ligature  of  the  external  iliac  or  femoral  (when  the 
condition  of  the  soft  parts  admits  of  it)  has  been  extolled  by  some 
surgeons  in  the  treatment  of  this  affection. §  A  larger  experience  shows, 
however,  that  when  cases  thus  treated  are  watched,  the  cures  cannot  be 

*  The  only  case  with  which  I  am  acquainted  is  one  quoted  by  Mr.  Erichsen  from 
Yelpeau  (^Noiiv.  EUm.  de  Med.  Ojjer.,  t.  i.  p.  175),  in  which  the  above  French  surgeon 
was  suddenly  caUed  upon  to  tie  the  external  iliac  for  a  knife-wound.  Though  there 
had  been  no  preliminary  dilatation  of  the  collateral  circulation  either  by  pressure  or  by 
the  presence  of  an  aneurysm,  the  result  was  successful. 

f  It  is  fair  to  state  that  Mr.  Bartleet,  of  Birmingham,  published  a  case  in  which  the 
external  iliac  was  tied  successfully  after  secondary  hajmorrhage  from  the  common 
femoral,  the  latter  having  been  tied  for  aneurysm  of  the  femoral  artery.  Previous  to 
ligature  of  the  external  iliac,  "  sponge-pressure  "  and  pressure  by  means  of  a  Martin's 
bandage  were  tried,  but  no  details  are  given.  It  is  noteworthy  that  the  catgut  ligature 
applied  to  the  femoral  in  this  case  came  away  on  the  seventh  day  (the  first  day  of  the 
haemorrhage)  unobserved,  and  surrounding  a  small  slough  of  the  arterj'.  It  had  been 
tied  "  tightly." 

X   Wonnds  and  Injuries  of  the  Arteries,  Lects.  v.  and  vi. 

§  An  apparently  successful  case  is  reported  by  Mr.  Leonard,  of  Bristol.  Measure- 
ments are  given  nearly  three  years  after  the  opeiation,  showing  that  the  success  was 
then  maintained.  Five  years  later  the  patient  reported  that  "  his  leg  was  much  the 
same"  as  at  the  last  report.  Bandaging  does  not  appear  to  have  been  made  use  of 
here.  Prof.  Buchanan  QUrit.  Med.  Journ.,  Nov.  23,  1867;  Si/d.  Soc.  Jiicn.  Iletr.,  1867-8, 
p.  300)  reports  a  case,  seven  months  after  the  operation,  apparently  cured  by  ligature 
of  the  external  iliac,  after  failure  of  rest  and  methodical  compression  (this  was  before 
the  introduction  of  Martin's  bandage).  Three  months  later  it  is  candidly  stated  that 
the  disease  had  recurred  to  a  considerable  degree.  Dr.  "White,  of  Harvard  University 
ilnternat.  Encycl.  of  Surg.,  vol.  ii.  p.  631),  quotes  Wernher  (reference  not  given)  as 
having  followed  up  thirty-two  cases  ;  in  all  there  was  an  immediate  reduction  of  size. 
but  the  relief  was  permanent  in  three  only.  Dr.  Pinnock,  of  Jlclbourne  (^Lancet,  1879, 
vol.  i.  p.  44),  gives  a  case  in  wliich  no  permanent  benefit  followed  on  ligature  of  the 
iemoral  artery. 


4  OPERATIONS  ON  THE  AEDOMEX. 

relied  upon  as  permanent.  Moreover,  too  little  value  has  been  attached^ 
in  reported  cures  by  ligature  of  the  main  vessel,  to  the  thorough  rest 
and  elevated  position  entailed  by  tying  the  artery. 

This  operation  should,  I  think,  be  reserved  for  those  cases  (which 
will  be  very  few)  in  which  Martin's  bandages  cannot  be  applied,  owing- 
to  cracks,  foul  ulcers,  or  burrowing  sinuses.  Here  the  ligature  may  be 
used  after  explaining  its  ]-isks  to  the  patient,  but  only  as  a  subsidiary 
measure.  The  bandage  will  have  to  be  used  as  well  later,  and  persisted 
in.  during  the  da}^  at  least,  probabl}^  for  life. 

4.  As  a  distal  operation  in  aneurysm  of  the  common  iliac. — Ligature  of 
the  external  iliac  has  been  so  unsuccessful  here  as  to  call  for  no  further 
comment. 

Surgical  Anatomy. 

Extent. — From  the  lumbo-sacral  articulation  to  a  point  just  internal 
to  the  centre  of  Poupart's  ligament.     Length — 3^  to  4  inches. 

Surface  Marking. — From  a  point  an  inch  below  and  to  the  left  of 
the  umbilicus  to  a  point  just  internal  to  the  centre  of  Poupart's. 
ligament. 

Relations: —  In  Front. 

Peritonaeum,  small  intestines. 
Iliac  fascia. 

Lymphatic  glands  and  vessels. 
Genito-crural  nerve  (genital  branch). 

Spermatic  vessels  }       Crossing  artery  near  Poupart's 

Circumflex  iliac  vein  j  ligament. 

Outer  Side.  Inner  Side, 

Psoas  (above).  External  iliac  Iliac  fascia. 

Iliac  fascia.  artery.  Vein. 

Behind. 

Iliac  fascia.  Vas  deferens  (dipping 

A'^ein  (above).  from  internal  ring 

Psoas  (below).  to  pelvis). 

Collateral  Circulation. 

Deep  epigastric  with  Internal  mammary,  lower  in- 

tercostals,  and  lumbar. 

Deep  circumflex  iliac  ,,  Ilio-lumbar,  lumbar,  and  glu- 

teal. 

Gluteal  and  sciatic  ,,  Internal  and  external  circum- 

flex. 

Comes  nervi  ischiadici  ,,  Perforating    branches    of   pro- 

funda. 

Obturator  ,,  Circumflex    arteries    and    epi- 

gastric. 

Internal  pudic  ,,  External  pudic. 

Operation. — (i)  By  the  lower  and  more  transverse  incision  of  Sir  A. 
Cooper.  (2)  By  the  higher  and  more  vertical  incision  of  Abernethy. 
The  two  are  compared  at  p.  7.  (3)  By  the  intra-peritonosal  method 
(p.  22). 


LIGATURE   OF  THE  EXTERNAL  ILTAC.  5 

(i)  Incisiox  of  Sir  A.  Cooper. — This  is  the  method  more  frequently 
made  use  of.  The  diet  having  been  limited,  and  the  bowels  having 
been  freely  moved  for  some  days  before  the  operation,  the  parts  shaved, 
iind  the  hip  slightly*  flexed,  an  incision  is  made  4  inches  long  (4^  to  5, 
if  there  be  very  much  fat,  or  if  the  parts  are  pushed  up  by  a  contiguous 
aneurysm),  parallel  with  Poupart's  ligament,  and  nearly  an  inch  above  it, 
commencing  just  outside  the  centre  of  the  ligament  and  extending  out- 
wards and  upwards  beyond  the  anterior  superior  spine. f  The  superficial 
fascia  and  fat,  varying  in  amount,  being  divided,  and  the  superficial 
circumflex  iliac  vessels  secured,  the  external  oblique,  both  fleshy  and 
ii]ioneurotic,  is  cut  through,  and  then  the  fleshy  fibres  of  the  internal 
()l)lique  and  transversalis.  This  is  done  either  by  using  the  knife  alone, 
lightly  and  carefully,  or  by  taking  up  each  layer  with  forceps,  nicking  it. 
and  slitting  it  up  on  a  director.  If  the  wound  be  sponged  carefully.:}:  a 
layer  of  cellular  tissue  can  usually  be  seen  between  the  muscles,  however 
thin  they  are.  Any  muscular  branches  should  be  secured  with  Spencer 
Wells's  forceps  as  soon  as  cut;  and  in  pushing  a  director  beneath  the 
muscles  as  little  damage  as  possible  should  be  done,  owing  to  the  prone- 
ness  to  cellulitis  later  on,  and  to  the  proximity,  in  a  thin  patient,  of  the 
peritonaeum.  The  fascia  transversalis,  when  exposed,  will  be  found  to 
vary  a  good  deal  in  thickness  and  in  the  amount  of  fat  which  it  contains. 
It  is  to  be  divided  very  carefully, §  and  the  extra-peritongeal  fat,  if  pre- 
sent, will  next  come  into  view.  First  one  and  then  two  fingers  being 
introduced,  the  peritonaeum  is  to  be  gentl}^  stripped  up  from  the  iliac; 
fossa  towards  the  middle  line — i.e..  upwards  and  inwards  as  far  as^  the 
inner  border  of  the  psoas.  ||  In  doing  this  care  must  be  taken,  especially 
in  the  dead  body,  not  to  separate  the  iliac  fascia  and  the  vessels  from 
their  position  on  the  psoas,  not  to  tear  this  muscle,  and  not  to  lacerate 


*  So  that  the  skin  may  not  be  too  much  relaxed  before  being  incised.  Later  ou,  to 
relax  the  parts,  the  hips  may  be  more  strongly  flexed, 

t  The  incision  may  have  to  be  made  higher  than  usual,  owing  to  the  upward  extension 
of  the  aneurysm,  to  enable  the  surgeon  to  tie  either  the  upper  part  of  the  external  or  the 
common  iliac.  Ou  this  point  see  the  remarks  on  the  comparison  of  Cooper's  and  Aber- 
nethy's  operations,  p.  7.  Often  in  these  cases  of  upward  extension  of  the  aneurysm 
the  sac  is  found  to  involve  the  lower  part  of  the  artery,  and  to  have  overlapped  the 
upper  portion. 

X  In  some  cases  where  the  circulation  has  been  much  interfered  with  by  an  aneurysm, 
most  copious  hiemorrliagc.  especially  venous,  has  been  met  with  in  the  earlier  steps  of 
this  operation. 

^^  Dr.  Sheen  {]}rit.  Med.  Joiirn.,  1882,  vol.  ii.  p.  720)  thus  writes  of  the  accident  which 
may  happen  here  :  •■  I  made  the  incision  somewhat  too  high,  and,  in  consequence,  opened 
the  peritonaeum,  which  I  mistook  for  transversalis  fascia.  Even  then  I  was  in  a  little 
doubt,  because  some  (omental)  fat  presented  itself,  which  very  much  resembled  the  fat 
.seen  in  the  previous  case  (fat  around  the  vessel),  but,  in  pushing  this  up  gently,  a 
knuckle  of  bowel  came  into  view,  which  settled  the  matter."  The  wound  in  the  peri- 
tonseum  was  sewn  up  with  two  fine  carbolised  sutures,  and  the  case  did  perfectly  well. 

II  Great  care  is  needed  here  if  the  peritonaeum  be  adherent.  This  condition,  when 
present,  is  usually  found  above.  It  is  especially  likely  in  long-standing  cases,  and 
where  the  aneurysm  has  caused  irritative  and  inflammatory  changes.  By  some  it  is  held 
that  the  transversalis  fascia  can  always  be  stripped  up  along  with  the  peritonieum.  As 
this  fascia  is  thickened  and  attached,  close  to  Poupart's  ligament,  to  form  the  deeper 
orural  arch  and  front  of  the  femoral  sheath,  it  is  very  doubtful  if  it  can  ever  be  detached 
unless  it  be  divided  or  torn  through.     The  latter  is  very  easy  on  an  aged  corpse. 


6  OPERATIONS  ON  THE  ABDOMEN. 

the  peritonEeum.  As  soon  as  the  peritonosum  has  been  well  raised,  an 
assistant  keeps  this  and  the  npper  lip  of  the  wound  well  out  of  the  way 
by  means  of  broad  retractors.  The  surgeon  then  feels  for  the  pulsation 
of  the  artery  on  the  inner  border  of  the  psoas,  and  carefull}^  opens  the 
layer  of  fascia  which  ties  the  vessel  to  the  psoas,  and  forms  a  weak 
sheath  to  it.  This  should  be  done  i;^  inch  above  Poupart's  ligament, 
so  as  to  lie  Avell  above  the  origin  of  the  deep  epigastric,  which  usually 
comes  off  j  or  i  inch  above  Poupart's  ligament,  and  the  needle  passed 
from  within  outwards,  carefully  avoiding  the  vein  on  the  inner  side  and 
the  genito-crural  nerve  oiitside  and  in  front.-    In  difficult  cases  the  liga- 

FlG.    I. 


To  show  the  incisions  for — A,  Ligature  of  the  external  iliac  artery.  B,  Ligature 
of  the  common  iliac  artery.  C,  Ligature  of  the  common  femoral  artery.  D,  Stran- 
gulated inguinal  hernia.     E,  Strangulated  femoral  hernia.     (Heath.) 


ture  (of  sterilised  silk,  or  kangaroo-tail)  must  mainly  be  passed  by  touch, 
but  a  free  incision,  adequate  use  of  retractors,  and  light  thrown  in  bj^  a 
large  mirror  will  usually  allow  the  surgeon  to  see  what  he  is  doing.  The 
effect  of  tightening  the  ligature  being  satisfactory,  it  is  cut  short  and 
dropped  in,  the  divided  muscles  are  then  brought  together  with  buried 
gut  sutures,  sufficient  drainage  provided,  and  the  superficial  wound 
closed.  The  parts  must  be  kept  relaxed  by  propping  the  chest  up  slightly 
and  flexing  the  knees  over  a  pillow,  but  too  much  flexion  of  the  groin  is 
to  be  deprecated  as  causing  a  deep  sulcus  from  which  possible  discharges 
ma}'  escape  with  difficulty.  The  limb  is  evenlj^  bandaged  from  the  toes 
upwards,  raised,  and  kept  covered  in  cotton-wool,  with  hot  bottles  placed 
in  the  bed.*    In  case  of  threatening  gangrene,  assistants  should  persevere 


*  If  the  patient  be  restless,  as  in  delirium  tremens,  a  long  splint  should  be  applied. 


LIGATURE   OF  THE  EXTERNAL  ILL\C.  7 

in  a  trial  of  friction  of  the  limb  fi'om  below  upwards.  Where  there 
is  a  history  of  syphilis,  appropriate  remedies  should  be  given  after  the 
operation. 

(2)  Incision  of  Abernethy. — In  his  first  operation  this  surgeon  made 
his  incision  in  the  line  of  the  arterj'  for  about  3  inches,  commencing 
nearly  4  inches  above  Poupart's  ligament.  Later  on  he  modified  his 
incision  by  making  it  less  vertical  and  more  curved,  with  its  convexity 
downwards  and  outwards,  and  extending  between  the  following  points — 
viz.,  one  about  i  inch  internal  and  i  inch  above  the  anterior  superior 
spine  to  li  inch  above  and  external  to  the  centre  of  Poupart's  ligament. 

Fig.  2. 


Anatomy  of 

1.  Abdominal  aorta. 

2.  Spermatic  vessels. 

3.  Inferior  vena  cava. 

4.  Ureter. 

5.  Obliquus  extei-nus. 

6  Geuito-crural  nerve. 

7  Obliquus  internus. 

8.  Psoas  fascia. 

9.  Transversalis. 


the  iliac  arteries  and  hernia. 

10.  External  cutaneous  nerve. 

11.  Epigastric  vessels. 

12.  Iliac  fascia. 

13.  Spei-matic  cord. 

14.  Section  of  transversalis. 

15.  External  abdominal  ring. 

16.  Section  of  obliquus  internus. 

17.  Saphenous  opening. 

18.  Section  of  obliquus  externus. 


The  respect i\e  advantages  and  disadvantages  of  the  methods  of 
Cooper  and  Abernethy  appear  to  be  the  following:  Cooper's  is  rather  the 
easier,  interfering,  as  it  does,  with  the  peritonaeum  less  and  lower  down. 
It  is  most  suitable  to  those  cases  which  do  not  extend  far,  if  at  all,  above 
Poupart's  ligament.  On  the  other  hand,  where  the  extent  to  which 
the  aneur3'sm  reaches  upwards  is  not  exactly  known,  Abernethy's 
operation,  hitting  off  the  artery,  as  it  does,  higher  up,  or  some  modi- 
fication of  that  given  (p.  16)  for  ligature  of  the  connnon  iliac,  will  be 
found  preferable. 


8  OPERATIONS  OX  THE  ABDOMEN. 

Difficulties  and  Possible  Mistakes. 

(i)  Too  short  an  incision.  Here,  as  in  colotomy  and  other  deep 
operations  on  the  abdominal  wall,  every  layer  must  be  cut  to  the  full 
extent  of  the  superficial  ones.  Otherwise  the  operator  will  be  working 
at  the  bottom  of  a  conical,  confined  wound.  (2)  A  wrongly  placed 
incision — i.e.,  one  which,  by  going  too  near  the  middle  line,  opens  the 
internal  abdominal  ring,  or  which,  if  too  low,  may  come  too  near  the 
cord.  (3)  Disturbing  the  planes  of  cellular  tissue  needlessly  or  roughly. 
(4)  Wounding  the  periton{:eum,  owing  to  a  hasty  incision  through  a 
thin  abdominal  wall,  by  rough  use  of  a  director,  especially  if  the  peri- 
tonaeum is  adherent  in  the  neighbourhood  of  the  sac,  or  fused  with  the 
transversalis  fascia.     The  peritonasum  is  often  difficult  to  distinguish;  it 

Fig.  3. 


Ligature  of  the  right  external  iliac  artery,  i,  External  oblique  aponeurosis. 
2,  Fleshy  fibres  of  internal  oblique  arid  transversalis.  3,  Transversalis  fascia. 
4,  Peritonffium  (drawn  up  by  the  retractor),  n,  Artery,  r,  Vein,  p,  Psoas  muscle. 
(Farabeuf.) 

is  bluish  in  aspect,  but  of  course  not  smooth,  being  covered  with  cellular 
tissue  which  connects  it  to  the  extra-peritonasal  fat.  (5)  Stripping  up 
the  peritonaeum  roughly  and  too  far.  (6)  Detaching  the  artery  from 
the  psoas.  (7)  Lacerating  the  psoas.  (8)  Tying  or  injuring  the  vein. 
(9)  Including  the  genito-crural  nerve.  (lo)  An  abnormal  position  of 
the  artery.  This  may  be  due  to  an  exaggeration  of  that  naturally 
tortuous  condition  of  the  artery  which  is  especially  likely  to  be  met  with 
in  patients  advanced  in  life.  Another  unusual  cause  of  displacement 
may  be  met  Avitli  in  extravasated  blood  when  an  aneurysm  has  given  ^^'ay. 

Sir  W.  Fergusson  briefly  reported  (^Brit.  Med.  Journ.,  1873,  vol.  i.  p.  286)  an  instance 
of  this  kind,  in  which  the  sac  gave  way  after  repeated  manipulation. 

Causes  of  Failure  and  Death. 

I.  Giangrene. — In  some  cases,  where  the  limb  does  not  become  gan- 
grenous, the  vitality  is  very  feeble  and  requires  much  attention. 

Thus,  iu  Mr.  Eiviugton's  case  QClin.  Soc.  Trans.,  vol.  xix.  p.  45),  loss  of  sensation  was 


LI(4ATURE  OF  THE  EXTEIIXAI.    IIJAC.  9 

■noticed  on  the  fourth  day,  followed  by  paralysis  of  most  of  the  muscles.  Tliough 
gangrene  did  not  appear,  and  the  patient  survived  five  and  a  half  months,  the  limb  was 
-"  on  the  verge  of  gangrene,"  as  shown  by  sores  appearing  on  the  heel  and  great  toe.* 

2.  Secondaiy  haemorrhage. — This  is  especially  likely  if  the  wcmiicl 
becomes  septic  and  if 'catgut  is  used.  This  fatal  result  may  be  long 
■deferred. 

Thus,  in  Mr.  llivington's  case  (loc.  supra  citS),  the  patient  died  of  secondary  haemor- 
rhage five  and  a  half  months  after  the  operation ;  the  wound  had  been  found  septic  at 
the  first  dressing ;  a  catgut  ligature  was  used. 

Early  recurrence  of  pulsation  may  be  ominous  of  secondary  ha3mor- 
rhage. 

In  a  case  of  Sir  A.  Cooper,  the  hiemorrhage  which  proved  fatal  a  fortnight  after  the 
operation  was  found  to  be  due  to  a  large  collateral — viz.,  an  abnormal  obturator  arising 
immediately  above  the  site  of  ligatitrc  (Roux,  Parallele  dc  la  Chir.  an/jlaisc  nrcc  la 
Chir.  francaise.  S)T.,  pp.  278,  279). 

3.  Cellulitis.  Septicaemia.  Pyaemia. — Owing  to  the  number  of 
planes  of  cellular  tissue  met  with  here,  any  needless  or  rough  dis- 
turbance of  the  parts,  inadequate  drainage,  or  a  septic  condition 
supervening  are  extremely  to  be  deprecated.  The  wound  should  be 
opened  up  at  once  if  any  collection  of  fluid  is  suspected.  4.  Peritonitis. 
5.  Tetanus,  from  including  the  genito-crural  nerve.  6.  Phlebitis  and 
secondary  haemorrhage  from  injury  to  the  external  iliac  vein.  7.  Sup- 
puration of  the  sac  with  its  attendant  dangers  of  septic  infection  and 
secondary  haemorrhage. t — This  accident  is  far  from  uncommon  in  eases 
of  inguinal  aneurysm  after  ligature.  Xo  pains  should  be  spared  to 
prevent  its  occurrence  by  taking  every  step  to  keep  the  wound  strictly 
aseptic  from  first  to  last,  and  thus  to  secure  early  and  sound  healing. 
Absolute  rest  should  also  be  enforced  upon  the  patient.  If  suppuration 
take  place  it  will  usually  be  within  two  months  of  the  date  of  ligature. 
The  symptoms  need  not  be  alluded  to  here  be^'ond  pointing  out  that 
pulsation  is  one  of  very  grave  omen.  When  it  is  evident  that  suppura- 
tion, if  not  established,  is  inevitable,  the  surgeon  should  so  arrange  his 
time  as  to  choose  a  suitable  occasion,  both  as  to  assistance  and  a  good 
light,  for  interfering.  Allowing  the  suppurating  sac  to  open  spon- 
taneously should  not  be  thought  of,  not  only  because  of  the  risk  of 
haemorrhage,  the  want  of  preparation.  &c.,  but  because  septic  infection 
is  now  made  very  probable.  The  operative  steps  are  much  the  same  as 
in  the  old  operation  for  aneurysm,  for  which  the  reader  is  referred  to 
p.  27.  It  may  be  here  pointed  out  that  in  this  case  there  is  more 
•chance  of  the  haemorrhage  taking  the  form  of  a  general  oozing  from  the 
sac,  and  not  that  of  a  gush  or  spirt  of  blood.  Moreover,  if  the  collateral 
circulation  has  Ijeen  well  establislied,  there  is  also  the  probability  of  the 
sac  being  fed  by  some  additional  branch,  which,  perhaps,  entering  deep 
down,  may  be   a    cause    of  much   embarrassment.      8.  Kecxarrence  of 

*  In  one  of  Dr.  Sheen's  cases  already  referred  to,  four  days  after  the  operation  a  large 
patch  of  skin  on  the  outer  side  of  the  thigh  was  noticed  to  be  darkish  in  colour,  ami  to 
pit  on  pressure,  though  normal  as  to  sensation.     The  case  did  quite  wclL 

t  Very  occasionally  secondary  Inemorrhage  may  take  place  to  a  slight  amount,  and 
leave  oii  spontaneously.  Thus,  in  one  of  Dr.  Sheen's  cases,  five  weeks  after  the  operation 
''  about  an  ounce  of  bright-red  blood  came  from  the  slight  remaining  wound,  and  a  slight 
oozinsraeain  after  a  few  da  vs.  but  there  was  no  further  hfemorrhage." 


lO  OPERATIONS  OX  THE  ABDOMEX. 

pulsation. — This  is  especiall}-  likely  to  occur  when  a  catgut  ligature  has- 
been  used  and  given  way.  owing  to  its  being  softened  by  suppuration. 
Over-free  collateral  circulation  will  cause  recurrence  of  pulsation  cjuickly ; 
and  melting  down  of  soft  coagulum  (this  appearing  to  be  all  that  the 
blood  can  do  in  the  way  of  clotting)  will  bring  about  the  same  cause  of 
failure  later  on.  In  these  cases  the  following  courses  are  open  in  the- 
matter  of  the  external  iliac — viz.,  well-adjusted  and  carefully-maintained 
pressure,  and  the  old  operation.  Ligature  of  the  vessel  lower  down — i.e.,. 
between  the  first  ligature  and  the  aneurysm — and  amputation  are  not 
available  here.*  Two  other  conditions  which  may  supervene  and  prove 
troublesome  should  be  mentioned  here — viz. :  9.  Formation  of  ia  ventral 
hernia. — This  should  be  prevented  as  far  as  possible  by  ensuring  primary 
union,  and  by  the  use  of  deep  chromic-gut  sutures  in  the  cut  muscles. 
Later  on,  if  this  complication  threaten,  an  appropriate  belt  should 
be  worn.  10.  Coming  away  of  the  ligature  long  after  the  operation, 
through  a  persistent  sinus  or  re-opened  wound. — This  may  happen,, 
even  in  a  wound  kept  sweet  from  first  to  last,  if  a  silk  ligature  has 
not  been  properly  sterilised,  or  if  one  of  too  close  textiire  is  used, 
8ee  footnote,  p.  552,  vol,  i. 


LIGATURE    OF    THE    COMMON"    ILIAC   (Figs.  4  and  5). 

Indications. — ^  ery  few  : 

I .  Aneurysms. — Especially"  those  inguinal  aneurysms  which  aifect  the 
external  iliac  in  its  upper  part,  above  the  origin  of  the  deep  epigastric, 
occupying  the  iliac  fossa  and  lower  part  of  the  abdomen.  When  such 
aneurysms  are  progressing  steadily,  when  they  have  resisted  a  trial  of 
pressure,  and  are  not  thought  amenable  to  the  old  operation,  ligature  of 
the  common  iliac  is  indicated. 

The  following  remarks  by  one  of  the  chief  living  authorities  on 
aneurysm,  Mr.  Holmes  (R.C.S.  Lectures,  Lancet,  1873,  vol.  i.  p.  297)^ 
will  aid  the  surgeon  in  coming  to  a  decision  in  this  most  important 
matter : 

'•  Allowing  that  an  iliac  aneurysm  is  amenable  to  all  three  methods  of  treatment — 
the  Hunterian,  by  ligature  of  the  aorta  or  common  iliac ;  the  old  operation,  by  laying 
open  the  sac  and  securing  the  artery  or  arteries  opening  into  and  out  of  it ;  and  the 
method  of  compression  applied  to  the  aorta  or  common  iliac, — I  think  no  one  could 
deny  that  the  number  of  cures  by  the  latter  method  bear.s  a  very  large  proportion  to  the 
ni;mber  of  cases  treated,  while  the  cures  by  the  Huutcriau  method  are  very  rare,  and 
the  other  method  is  as  yet  pretty  nearly  untried. 

"  But  this  is  far  from  settling  the  question ;  compression,  doubtless,  often  succeeds 
but  it  also  often  fails.  It  is  not  without  its  risks.  It  usually  requires  the  prolonged 
use  of  chloroform,  and  this  cannot  always  be  borne  by  the  patient. 

'•  The  qitestiou  of  applying  the  old  method  in  preference  to  the  Hunterian  in  those 


'•  In  one  case  ^Syd.  Soc.  Bien.  Retr.,  1873-4,  p.  220),  after  ligatitre  of  the  external 
iliac  for  a  femoral  aneurysm  with  catgut,  and  premature  absorption  of  this  on  the  fifth 
day  (the  wound  suppurated  freely,  and  antiseptic  precautions  do  not  appear  to  have 
been  taken),  pulsation  returned,  and  the  swelling  enlarged.  The  patient  was  operated 
upon  again,  and  a  stout  carbolised  hempen  ligature  made  use  of,  one  end  being  left 
long.  Though,  owing  to  the  close  matting  of  parts,  the  peritonaeum  was  wounded  twice^ 
and  intestines  and  omentum  protruded,  the  patient  recovered. 


LIGATURE  OF  THE  COMMON   ILIAC.  II 

cases  (rare,  it  may  be,  but  which  must  sometimes  be  met  with)  in  which  pressure  has 
failed,  is  one  which  Mr.  Sj'me's  brilliant  operations  have  put  in  a  totally  new  light. 
And  I  must  say,  for  my  own  part,  that,  looking  at  the  a^^•ful  mortality  which  has 
attended  the  ligature  of  the  common  iliac  for  aneurysm,  and  the  uniform  fatality  of  the 
same  operation  on  the  aorta,  I  think  Mr.  Symc's  suggestion  ought  to  be  put  to  the  test  of 
more  extended  experience,  although  the  facts  and  reasonings  which  I  have  adduced  will 
show  that  I  am  not  insensible  to  the  risks  which  attend  the  performance  of  the 
operation,  to  the  probability  of  secondary  hajmorrhage,  and  to  the  extensive  injury 
which  must  be  inflicted  upon  parts  in  the  immediate  neighbourhood  of  important 
organs." 

Mr.  Holmes  then,  in  proof  of  the  great  fatality  of  the  Hunterian  operation  on  the 
common  iliac,  quotes  the  list  collected  by  Dr.  Stephen  Smith  (^Amer.  Jonrn.  Med.  Sci.. 
July  i860,  vol.  xl.),  in  which,  out  of  fifteen  cases  in  which  that  vessel  was  tied  for 
aneurysm,  only  three  can  be  reckoned  as  definitely  cured. 

Mr.  Holmes's  belief  that  subsequent  experience  has  not  been  more  favourable  is 
supported  by  a  table  of  65  cases,  tabulated  hj  Dr.  Packard.*  Of  these  65  cases,  no 
fewer  than  51  died,  only  14  recovering,  giving  a  general  mortality  of  78-46  per  cent.f 

Mr.  Holmes  goes  on  to  discuss  the  old  operation,  and,  in  answer  to  the  objection  that, 
though  the  Hunterian  operation  has  been  attended  with  "a\\"ful  mortality"  here,  we 
are  not  made  more  secure  by  operating  on  an  artery,  perhaps  not  much  more  than  three 
inches  lower  down,  and  already  involved  in  disease,  writes :  "  I  reply  that  if  we  grant 
the  artery  where  it  is  involved  in  the  sac  to  be  healthy  enough  to  bear  the  ligature, 
many  advantages  may  be  found  in  the  old  operation  over  that  of  Hunter.  .  .  .  First, 
the  clot  is  removed  and  the  sac  laid  open ;  consequently,  that  softening  of  clot  and 
inflammation  of  a  closed  sac  lying  in  proximity  to  the  peritonaeum,  which  is  so  surely 
fatal,  is  obviated.  Next,  the  ligature  will  probably  be  placed  on  the  external  iliac 
instead  of  the  common,  and  thus  the  chances  of  gangrene  will  be  greatly  diminished, 
since  the  internal  iliac  and  its  branches  are  left  open.  Thirdly,  the  artery  is  tied  at  a 
point  where  most  likely  the  peritonseum  and  viscera  have  been  pushed  away  from  it  by 
the  sac,  so  that  there  is  less  risk  of  hurtful  interference  with  these  latter  in  the 
operation.  And,  lastly,  the  total  excision  of  the  tumour  precludes  any  such  relapse  as 
occurs  sometimes  after  the  Hunterian  operation. 

"  Against  these  advantages  must  be  set  the  undoubted  risks  of  secondary  haemorrhage, 
even  in  cases  where  the  immediate  dangers  of  the  operation  have  been  surmounted. 
■\Miat  this  risk  is  we  have  no  means  of  judging  until  our  experience  of  this  operation 
becomes  greater ;  but  I  am  under  the  impression  that  Mr.  Syme  much  underrated  it,  in 
consequence  of  having  operated  chiefly  upon  traumatic  aneurysm." 

Farther  on,  Mr.  Holmes  writes,  while  •"  maintaining-  that  the  old 
doctrine  on  which  the  superiority  of  Hunter's  operation  is  based  is  quite 
true  in  general,  I  should  have  no  objection  in  the  particular  instance  of 
iliac  aneurysm  to  follow  Mr.  Synie's  practice;  at  least,  until  further 
experience  of  it  should  show  that  it  is  wrong :  only  tlie  less  dangerous 
expedient  of  rapid  compression  of  the  trunk  artery  under  chloroform,  or 
gradual  compression,  with  or  without  chloroform,  should  first  be  tried." 

*  Trans.  Amer.  Surg.  Assoc,  vol.  i.  p.  234.  Sixty-seven  cases  are  given,  but  the  result 
is  not  stated  in  two. 

f  Grouping  these  cases  into  classes,  after  Dr.  Smith's  example,  in  order  to  obtain 
more  satisfactory  deductions,  Dr.  Packard  concludes  as  follows  : — (i.)  Those  cases  in 
which  the  operation  was  done  for  the  arrest  of  hiemorrhage :  22  cases,  of  which  19  died 
and  3  recovered ;  mortality,  86-36  per  cent,  (ii.)  Those  in  which  it  was  done  for  the 
cure  of  aneurysm  :  35  cases,  of  which  24  died  and  g  recovered,  the  result  not  being  stated 
in  2 ;  mortality  in  33  cases,  72-72  per  cent,  (iii.)  Those  cases  in  which  tumours  simu- 
lating aneurysm  led  to  its  performance :  5  cases,  4  of  which  die^l  and  1  recovered 
(iv.)  Those  in  which  the  vessel  was  secured  to  prevent  hiemorrhage  tluring  the  removal 
of  a  morbid  growth :  5  cases,  all  of  which  died. 


12  OPERATIOXS  OX  THE  ABDOMEN. 

The  same  authority,  when,  later  on.  discussing  the  value  of  pressure, 
l3rings  out  the  following  facts.  That,  while  rapid  compression  under 
chloroform  is  a  mode  of  treatment  by  which  most  gratifj^ng  success  has 
been  obtained  in  iliac  as  well  as  aortic  aneurysm,  it  exposes  the  patient 
to  serious  dangers.  Amongst  these  are  enteritis  and  peritonitis  from 
bruising  of  small  intestine,  mesentery,  meso-colon,  and  sympathetic; 
hoematuria;  failure  of  pulse  and  breathing  when  the  pad  is  screwed 
down.  On  account  of  these  very  real  dangers,  which  every  dexterity 
may  not  obviate.  Mr.  Holmes  advocates  a  trial  of  gradual  compression, 
as  safer  though  less  efficient,  and  he  points  out  that  the  relations  of  the 
common  iliac  are  less  complicated  than  those  of  the  aorta,  and  "  as  we 
get  further  to  one  side,  there  is  more  chance  for  the  intestines  to  slip  out 
of  the  wa}"."* 

2.  Wounds. — These  may  be  gunshot  or  ba3'onet  wounds,  or  knife- 
stabs  of  the  vessel  itself,  or  the  internal  iliac  or  its  branches,  usually  the 
latter.  The  luemorrhage  calling  for  ligature  seems  to  be  usually 
secondary.!  Gunshot  wounds  of  the  common  iliac  have  a  fresh  interest 
now.  owing  to  the  recent  advances  in  surgery  in  the  treatment  of  gunshot 
wounds  of  the  abdomen. 

Dr.  S.  Smith  J:  gives  two  cases  of  ligature  of  the  common  iliac  for 
wounds  : 

One  was  from  a  musket-ball  which  injured  the  vessel  itself,  passed  through  the 
intestines,  and  lodged  in  the  sacrum.  The  operation  was  performed  by  opening  the 
peritonjeal  cavity.  Peritonitis  soon  set  in ;  secondary  haemorrhage  recurred  repeatedly, 
and  the  case  ended  fataUy  on  the  tif teenth  day.  The  other  case  is  of  great  interest,  as 
the  common  and  internal  iliac  were  here  tied  for  severe  haemorrhage  after  a  stab  in  the 
inguinal  region.  A  large  quantity  of  blood  was  found  in  the  peritomeal  cavity,  and  the 
patient  died  ten  hours  after  the  operation.  At  the  necropsy  it  was  found  that  the  deep 
epigastric  "was  the  wounded  vessel. 

Dr.  Otis§  records  four  cases  of  ligature  of  the  common  iliac  during 
the  American  Civil  "War  : 

In  one,  a  gunshot  wound,  in  which  the  baU  entered  the  groin  and  came  out  at  the 
buttock,  the  external  iliac  was  first  tied,  the  repeated  haemorrhages  being  believed  to  be 
from  the  profunda ;  but  as  the  bleeding  persisted  and  evidently  came  from  the  sciatic, 
the  wound  was  prolonged  and  the  common  iliac  tied.  Both  ligatures  came  away,  and 
the  operation  wound  healed,  but  the  f.atient  died  about  three  months  later  of  exhaus- 
tion, associated,  apparently,  with  necrosis  in  the  gluteal  region.  In  the  second  case 
the  common  iliac  was  tied  for  a  gunshot  wound  believed  to  be  of  the  gluteal  artery,  in 
which  the  haemoiThage  was  not  arrested  by  tying  the  internal  iliac.  The  hajmorrhage 
recurred,  and  death  took  place  two  days  later.  The  third  case  was  one  of  diffuse 
aneurysm  of  the  right  buttock  and  iliac  fossa  resulting  from  a  bayonet-stab  in  the 

*  Mr.  Holmes  draws  attention  also  to  this  most  important  point — i.e.,  that  rapid 
coagulation  in  an  aneurysmal  tumour  cannot  be  regarded  as  in  itself  a  means  of  cure, 
but  only  as  the  commencement  of  a  process  which,  if  not  interrupted,  may  result  in 
cure,  and  that  thus,  while  pulsation  may  diminish  soon  after  a  trial  of  compression,  it 
may  not  absolutely  cease  for  quite  a  month. 

f  It  would  naturally  be  thouglit  that  haemorrhage  from  a  wound  of  the  common 
iliac  would  be  fatal  before  a  ligature  could  be  applied.  Dr.  Otis  gives  a  case  in  which 
this  vessel  was  wounded  by  a  ball  entering  from  the  buttock  through  the  sacro-iliac 
.synchondrosis.     Death  took  place  from  hemorrhage  on  the  second  day. 

J  Amer.  Jonrn,  Jtlcd.  Sci.,  i860,  vol.  xl.  p.  17. 

§  Med.  and  Sury.  Hist,  of  the  Mar  of  the  lU-hdlion.  pt.  ii.  p.  333. 


LIGATURE  OF  THE  COM3iOX   ILIAC.  13 

former  region.  Death  took  place  four  days  later  from  gangrene  of  the  sac.  The  old 
operation  is  considered  by  Dr.  Otis  to  have  been  preferable  in  this  case,  but  as  the 
necropsy  showed  that  the  anterior  trunk  of  the  internal  iliac  had  been  wounded,  %\-ithin 
the  sacro-sciatic  notch,  by  the  bayonet,  it  is  difficult  to  see  how  the  case  could  have 
been  treated  save  by  ligature  of  the  internal  iliac,  either  outside  or  ^vithin  the  peri- 
tonteum,  and  then  by  opening  and  filling  the  aneurysmal  sac  with  aseptic  gauze  or 
sponges.  The  fourth  case  was  one  of  aneurysmal  varix  of  the  femoral  vessels  from  a 
punctured  wound  two  inches  below  Poupart's  ligament.  In  this  case,  owing  to  the 
impossibility  of  separating  the  peritonaeum,  this  was  incised,  and  the  common  iliac 
thus  secured.  Peritonitis  proved  fatal  four  days  later.  Here  ligature  of  the  arterr 
lower  down,  above  and  below  the  original  seat  of  injury,  would  have  been  better 
treatment. 

3.  For  the  arrest  of  haemorrhage  apart  from  aneurysm. — SiTch  cases 
may  be  met  witli  afrer  amputation  near  the  hip.  follo^^•ed  by  secondary 
htemorrhage  from  the  branches  of  the  internal  iliac  in  what  is  usuallv 
the  posterior  flap. 

Mr.  Listen  QLond.  Jled.  Gaz..  April  24,  1830)  published  a  case  of  this  kind  in  which, 
after  amputation  below  the  trochanter  minor  for  necrosis  of  the  femur,  haemorrhage 
occurred  from  the  stump  on  the  seventh  day.  As  this  could  not  be  arrested,  the 
common  iliac  was  tied,  but  the  patient  died  twenty-four  hours  later. 

Dr.  Packard  iloc.  supra  cit.,  footnote,  p.  10)  treated  a  somewhat 
similar  case  in  the  same  way,  successfully. 

This  case  is  especially  interesting,  as  the  haemorrhage  occurred  from  branches  of 
the  internal  iliac  after  a  Furueaux  .Jordan's  amputation,  a  method  which  has  latelv 
come  largely  into  vogue,  and  which  would  usually  be  expected  to  do  awav  with 
the  above  risk.*  Hjemorrhage  occurred  from  the  stump  on  the  sixth  day,  and.  as 
pressure  failed,  the  common  iliac  was  tied.     The  patient  ultimately  did  well. 

It  will  not.  it  is  hoped,  seem  a  hasty  criticism  on  the  above  if  I  sav 
that  in  future  cases  opening  up  the  flaps  and  plugging  with  aseptic 
gauze,  or  the  application,  for  some  days,  of  Spencer  Wells's  forceps, 
aided  by  even  pressure  on  the  flaps  and  pressure  on  the  common  or 
external  iliac,  would  be  preferable  to  submitting  the  patient  here  to  the 
severe  and  risky  operation  of  ligature  of  the  common  iliac. 

4.  For  pulsating  tumours  simulating  aneurysm. — As  these  growths 
from  the  iliac  fossa  and  the  Avails  of  the  pelvis  have  been  found  to  be 
malignant,  it  is  of  the  utmost  importance  to  form  a  correct  diagnosis  in 
these  cases,  and  thus  save  a  j^atient  who  has  a  certainly  fatal  disorder 
from  being  submitted  to  an  operation  which  is  most  dano-erous,  and 
almost  certain  to  be  useless.f  As  mistakes  have,  however,  been  made 
in  these  cases  by  excellent  surgeons, J  the  chief  points  of  diagnosis,  as 


*  In  Dr.  Packard's  case  the  Furneaux  Jordan's  amputation  was  performed  probably 
higher  up  than  iisual,  owing  to  osteo-myelitis,  after  a  previous  amputation  for  growth, 
at  about  the  middle  of  the  thigh. 

t  In  Guthrie's  case,  a  pulsating  tumour  in  the  right  buttock,  the  size  of  an  adult 
head,  diminished  by  one-half  in  a  month.  Two  mouths  later  it  again  cidarsed.  and 
the  patient  dying  eight  months  after  the  operation,  an  immense  encephaloid  tumour 
wiis  found  occupying  the  right  iliac  region. 

%  E.g..  Guthrie  ^Lond.  Med.  Gaz..  vol.  ii.  1S34) ;  Stanley  QMed.-CJiir.  Tram.,  vol. 
xxviii.)  ;  Moore  (ibid.,  vol.  xxxv.). 


14  OPERATIONS  ON  THE  ABDOMEN. 

given  by  Mr.  Holmes,*  maybe  briefly  mentioned  here:  (i)  The  bruit 
is  usually  less  well  marked ;  (2)  the  pulsation  is  less  heaving  and  less 
expansile ;  (3)  the  condition  of  the  bone  with  which  the  swelling  is 
connected ;  thus  a  plate  of  bone  may  be  found  in  the  supposed  aneu- 
rysmal sac ;  the  supposed  aneurysm  may  be  found  both  on  the  gluteal 
and  the  iliac  aspects  of  the  pelvis,  the  bone  being  expanded  b}^  the 
growth.  (4)  Cancerous  cachexia  may  be  present,  and  perhaps  secondary 
growths  as  well. 

5.  For  haemorrhage,  not  the  result  of  a  wound. — Ligature  of  the 
common  iliac  has  been  employed  in  some  cases  of  this  nature,  usually 
secondar}^  hfemorrhage  after  ligature  of  the  external  iliac,  the  gluteal 
and  sciatic,  or  after  rupture  of  the  external  iliac.  Ligature  of  the  main 
trunk  has  been  so  fatal  here  that  it  should  be  abandoned ;  carefuU}'- 
applied  pressure,  aided  by  pluggiiig  with  aseptic  gauze,  or  the  old 
operation,  being  certainly  preferable. 

Mr.  Morrant  Baker  has  put  on  record  t  a  case  of  great  interest  in  diagnosis,  in  which 
an  abscess  from  sacro-iliac  disease  ulcerated  into  branches  of  the  internal  iliac  artery, 
and  when  opened  gave  rise  to  hiemorrhage  calling  for  ligature  of  the  common  iliac. 
A  gardener,  aged  17,  had  felt  pain  a  month  previously  while  digging.  A  tense,  elastic 
swelling,  distinctly  fluctuating,  and  acutely  tender,  occupied  all  the  right  buttock.  It 
was  opened,  and  a  small  stream  of  apparently  arterial  blood  escaped  without  jets.  On 
further  exploration  the  finger  entered  a  large  cavity  between  the  iliac  bone  and  the 
glutei.  The  iliac  fossa  was  full  and  tense,  and  on  examination  per  rectum  a  swelling 
was  found  in  the  right  ischio-rectal  fossa.  On  enlarging  the  gluteal  wound  a  steady 
stream  of  arterial  blood  welled  up  through  the  great  sacro-sciatic  foramen.  This  was 
firmly  plugged,  and  the  common  iliac  tied.  On  removing  the  plug  some  bleeding  still 
occurred,  but  was  easily  arrested.  The  gluteal  wound  became  offensive,  and  this  region, 
together  with  the  upper  part  of  the  thigh,  became  gangrenous,  the  leg  and  foot  remain- 
ing unaffected.     The  patient  died  forty  hours  after  the  operation. 

At  the  necropsy  the  sacro-iliac  joint  was  open,  with  surrounding  caries.  The  remains 
of  a  large  abscess  were  found,  involving  the  branches  of  the  internal  iliac.  There  was 
no  trace  of  aneurysm. 

6.  Preparatory  to  the  removal  of  caries  of  pelvis. — Where,  after 
amputation  at  the  hip-joint,  pelvic  caries  persists,  leading  steadily  to 
lardaceous  disease,  I  think  an  attempt  should  be  made  to  remove  all 
of  the  innominate  bone  which  is  diseased.  Such  profuse  oozing  follows 
that  the  common  iliac  should  first  be  tied. 

I  adopted  this  course  in  a  boy  aged  9,  eleven  years  ago.  The  common  iliac  was  most 
easily  tied  by  the  free  anterior  abdominal  incision  given  below,  and  the  pubic  part  of 
the  bone  removed  the  same  day.  A  little  later  I  removed  the  ischium  and  the  acetabu- 
lar portion  of  the  ilium,  leaving  the  upper  half.  Bronchitis  (increased,  I  fear,  by  the 
ether  given  at  the  second  operation)  carried  off  the  child  three  weeks  after  ligature  of 
the  common  iliac.  The  bleeding  was  slight  and  easily  arrested,  the  chief  difficulty  met 
with  here  being  the  detachment  of  the  soft  parts  in  the  neighbourhood  of  the  pubes, 
tuber  ischii,  and  sacro-iliac  joint.  The  thickening  of  the  pelvic  fascia,  present  in  these 
advanced  cases,  shuts  off  the  contents  of  the  pelvis. 

Surgical  Anatomy. — The  common  iliacs,  coming  off  on  the  left  side 
of  the  fourth  lumbar   vertebra,   incline    downwards   and    outwards   to 

*  Sj/st.  of  Surf/.,  vol.  iii.  pp.  44,  145.  The  reader  should  also  consult  Mr.  Holmes's 
article,  "  On  Pulsating  Tumours  which  are  not  Aneurysmal,  and  on  Aneurysms  which 
are  not  Pulsating  Tumours"  QSt.  Georr/e's  Hosi).  Rep.,  vol.  vii.). 

t  St.  liarthol.  JIo.<tp.  Rep.,  vol.  viii.  p.  120. 


LIGATURE   OF  TIIJ-:  (  OMMCJX   ILIAC. 


divide,  opposite  to  the  lunibo-sacral  intervertebral  disc,  into  tlie  internal 
and  external  iliacs.  The  right  is  rather  the  longer  and  more  oblique 
of  the  two.  Their  length  is  usually  an  inch  and  a  half.  Their  In-anches 
are  few  and  small — viz..  to  the  ureter,  psoas  muscles,  glands,  &c.  The 
iliacs  become  increasingly  tortuous  with  age :  a  point  of  importance  in 
tying  the  vessel  on  an  aged  corpse. 

Line. — One  drawn  from  a  point  li  inch  below  and  a  little  to  tlie  left 
of  the  umbilicus  to  the  centre  of  Poupart's  ligament,  the  line  curving 
a  little  outwards,  will  represent  the  course  of  the  artery  witli  sufficient 
accuracy. 

Guide. — The  above  line  is  the  only  surface  guide  :  more  deeph'  the 
lumbo-sacral  articulation  and  the  psoas  muscles  are  useful  guides, 
especially  in  a  thin  subject.* 

Kelations: —  I\  Front. 

Peritongeum ;  small  intestine ;  csecum  and 

appendix,  sometimes. 
Ureter. 
Sympathetic. 

Outside. 
Psoas. 
Vena  cava. 
Kight  common 
iliac  vein. 

Behind. 

Right  and  left  common  iliac  veins. 


Ei.trht  common 
iliac  artery. 


Inside. 
Left  common  iliac  vein. 


Outside. 
Psoas. 


In  Front. 
Peritonaeum ;  small  intestine. 
Sympathetic. 
Ureter. 
Superior  hasmorrhoidal  artery. 


Left  common 
iliac  arteiy. 


Behind. 
Left  common  iliac  vein. 
Collateral  CircTilation. — The  chief  vessels  are  : 


Above. 
Internal  mammary  and 

lower  intercostals 
Lumbar 

Middle  sacral 
Superior  haemorrhoidal 


Below. 


with  Deep  epigastric. 

„  llio-lumbar     and     circumflex 

iliac. 
„  Lateral  sacral. 

„  Inferior  and  middle   liEemor- 

rhoidal. 


In  addition,  the  pubic  arteries  anastomose  behind  the  symphysis. 


*  Attention  has  been  drawn  to  the  need  of  employing  touch,  as  well  as  sight,  in  the 
ligature  of  these  large  trunks  (p.  6). 


1 6  OPERATIONS  OX  THE  ABDOMEN. 

Operations  (Figs.  4  and  5). — The  common  iliac  ma}"  be  tied  by  opera- 
tions based  tipon  one  of  three  incisions  :  (i)  An  anterior  abdominal,  by 
wliich  tlie  "\'essel  is  approached  more  directly  from  the  front;  an 
incision  based  upon  those  for  tying  the  external  iliac,  and  made  use  of 
by  Dr.  Mott,  of  New  York,  who  first  tied  this  vessel  for  aneurysm  in 
1827.  (2)  A  posterior  abdominal,  or  loin  incision,  by  which  the  vessel 
is  reached  from  behind ;  a  method  made  use  of  by  Sir  P.  Crampton,  of 
Dublin,  in   1828,   and  by  Mr.  Stanley,  at  St.  Bartholomew's,  in   1846 

(i)  Anterior  Abdominal  Incision. — The  preparatory  treatment  is  here' 
the  same  as  that  for  the  external  iliac.  The  ]iarts  being  shaved  and 
cleansed,  a  curved  incision,  5  to  8  inches  long,  according  to  the  amount 
of  fat,  the  development  of  the  body,  and  the  size  of  the  aneiirvsm,  is 
made,  commencing  just  outside  the  centre  of  Poupart's  ligament  and 
li  inch  above  it,  then  carried  outwards,  reaching  towards  the  crest  of 
the  ilium,  then  upwards  towards  the  ribs,  and  finally  curving  inwards 
towards  the  umbilicus,  till   sufficiently  free  to  admit  of  the  necessary 

Fig.  4. 


Ligature  of  the  left  common  iliac  artery.  The  peritonseum  has  been  drawn 
upwards  and  inwards,  and  the  Lifui-cation  of  the  common  iliac  artery  exposed. 
(Compare  Fig.  i,  B,  and  Fig.  2.)     (Heath.) 

manipulations  for  i-eaching  the  artery.  The  three  abdominal  muscles 
are  cut  through,  either  on  a  director,  or  with  careful  light  sweeps  of 
the  knife,  till  the  fascia  transversalis  is  reached;  anj^  vessels  which 
bleed  being  at  once  secured  with  Spencer  Wells's  forceps.  The  fascia 
transversalis,  which  may  generally  be  known  from  the  peritonasum  by 
tlie  laj'^er  of  extra-peritona3al  fat  Mdiicli  usually  intervenes  between  the 
two,  is  then  picked  up  and  divided  on  a  director,  at  the  lower  part  of  the 
wound  where  it  is  best  marked.*  Adoption  of  the  Trendelenberg  posi- 
tion will  facilitate  the  remaining  steps.  The  peritonaeum  is  next  raised 
upwards  and  inwards,  first  one  finger,  and  then  more,  being  insinuated 
towards  the  middle  line  until  the  psoas  is  reached.  On  the  inner  side 
of  tliis  muscle  the  artery  will  be  found,  the  external  iliac  being  traced 
u])  if  needful.      In  order  to  aid  the  surgeon  in  the  difficulties  which 

*  Dr.  Liddell  Qlntern.  Encycl.  of  Surr/.,  vol.  iii.  p.  312)  recommends  that  the  separa- 
tion of  this  fascia  from  the  peritonfeum  should  be  begun  at  the  upper  part  of  the 
wound,  where  the  adhesion  is  slightest. 


LIGATURE  OF  THE  COMMON  ILIAC. 


17 


are  now  met  with,  owing  to  the  arteiy  l}'ing  at  the  bottom  of  a  very- 
deep  wound,  the  abdominal  walls  should  be  relaxed  by  bending  up 
the  thighs,  the  wound  sponged  thoroughly  dry,  and  light  thrown  in 
by  a  reflector  or  electric  lamp.  Care  will,  of  course,  have  been  taken 
to  divide  every  layer  from  end  to  end  equally,  and  thus  to  avoid  a 
conical  type  of  wound.  The  position  of  the  vessel  having  been  made 
out,  it  is  to  be  cleaned  with  a  director,  especial  care  being  taken  on 
the  right  side,  as  here  both  the  common  iliac  veins  lie  behind  the 
artery.     The  needle  should  be  passed  from  within  outwards. 

(2)  Posterior    Incision,  partly    in   Abdomen,  parthj    in    Loin. — This 

Fig.  5. 


£faaK 

Ligature  of  common  iliac  by  a  posterior  iucision.     This  would  also  be 
available  lor  the  abdominal  aorta.     (Br3-aut.) 

operation  will  be  best  given  in  the  words  of  Sir  P.  Crampton,^ 
first  introduced  it : 


who 


"  The  first  incisionf  commenced  at  the  anterior  extremity  of  the  last  false  rib, 
proceeding  directly  downwards  to  the  ilium;  it  followed  the  line  of  the  crista  ilii, 
keeping  a  very  little  within  its  inner  margin,  until  it  terminated  at  the  superior 
anterior  spinous  process  of  that  bone ;  the  incision  was  therefore  chiefly  curvilinear, 
the  concavity  looking  towards  the  navel.  The  abdominal  muscles  were  then  divided 
to  the  extent  of  about  an  inch,  close  to  the  superior  anterior  spinous  process,  down  to 
the  peritoniEum ;  into  this  wound  the  forefinger  of  the  left  hand  was  introduced,  and 
passed  slowly  and  cautiously  along  the  line  of  the  crista  ilii,  separating  the  peri- 
toniBum  from  the  fascia  iliaca.  A  probe-pointed  bistoury  was  now  passed  along  the 
finger  to  its  extremity,  and  by  raising  the  heel  of  the  knife,  while  its  point  rested 
firmly  at  the  end  of  the  finger  as  on  a  fulcrum,  the  abdominal  muscles  were  separated 
from  their  attachments  to  the  crista  ilii  by  a  single  stroke.  By  repeating  this 
manoeuvre  the  wound  was  prolonged  until  sufticient  room  was  obtained  to  pass  down 
the  hand  between  the  peritonaeum  and  the  fascia  iliaca.  Detaching  the  very  slight 
connections  which  these  parts  have  with  each  other.  I  was  able  to  raise  up  the  pcri- 
tonaeal  sac,  with  its  contained  intestines,  on  the  palm  of  my  hand  from  the  psoas 
magnus  and  iliacus   internus  muscles,  and   thus   obtain  a  distinct   view  of   all   the 


*  Mcd.-Chir.  Trans.,  vol.  xvi.  p.  161. 

t  The  patient  would,  of  course,  be  rolled  over  on  to  the  sound  side. 
VOL.   IL 


1 8  OPERATIONS  ON  THE  ABDOMEN. 

important  parts  beneath ;  and  assuredly  a  more  striking  view  has  seldom  been 
presented  to  the  eye  of  the  surgeon.  The  parts  were  unobscured  by  a  single  drop  of 
blood :  there  lay  the  great  iliac  artery,  nearly  as  large  as  my  finger,  beating  awfully, 
at  the  rate  of  120  in  a  minute,  its  yellowish-white  coat  contrasting  strongly  with  the 
dark  blue  of  the  iliac  vein  which  lay  beside  it,  and  seemed  nearly  double  its  size; 
the  ureter  in  its  course  to  the  bladder  lay  like  a  white  tape  across  the  artery,  but 
in  the  process  of  separating  the  peritoneum  it  was  raised  from  it  with  that  membrane, 
to  which  it  remained  attached.  The  fulness  of  the  iliac  vein  seemed  to  vary  from 
time  to  time,  now  appearing  to  rise  above  the  level  of  the  artery,  and  now  to  subside 
below  it.  Nothing  could  be  more  easy  than  to  pass  a  ligature  round  an  artery  so 
situated.  The  forefinger  of  the  left  hand  was  passed  under  the  artery,  which,  with 
a  little  management,  was  easily  separated  from  the  vein;  and  on  the  finger  (which 
served  as  a  guide)  a  common  eyed  probe,  furnished  with  a  ligature  of  moistened 
cato-ut,  was  passed  under  the  vessel.  A  surgeon's  knot  was  made  in  the  ligature, 
and  the  noose  gradually  closed,  until  Mr.  Colles,  who  held  his  hand  pressed  upon  the 
tumour  announced  that  all  pulsation  had  ceased.  A  second  knot  was  then  made, 
and  one  end  of  the  ligature  cut  off  short."  Unfortunately,  the  catgut  of  that  day 
became  quickly  dissolved,  pulsation  returned  in  the  tumour  within  fifty  hours  of  the 
operation,  and  on  the  tenth  day  profuse  secondary  hfemorrhage  took  place,  death 
following  immediately. 

Comparison  of  the  Two  Methods. — Sir  P.  Crampton  thus  speaks 
of  his  own  and  Dr.  Mott's  operation  :  "  The  operation  of  tying  the 
common  iliac  artery  is  not  only  a  feasible  but  (when  performed  in 
the  manner  described  in  this  paper)  an  exceedingly  easy  operation. 
The  difficulties  which  Dr.  Mott  encountered,  and  which  prolonged  the 
operation  to  nearly  an  hour,*  are  clearly  referable  to  the  circumstance 
of  his  incision  having  been  made  too  low.  This,  in  the  first  place, 
brouo-ht  him  in  contact  with  the  aneurysmal  tumour,  from  which  he 
was  obliged,  with  great  labour  and  considerable  risk,  to  detach  the 
peritoneeum ;  then  he  had  the  whole  mass  of  the  tumour  between  him 
and  the  artery  which  he  was  to  tie ;  and,  lastly,  he  had  the  intestines 
pressing  down  upon  him  and  producing  such  a  complication  of  diffi- 
culties as  I  believe  few  men  but  himself  could  have  encountered  with 
success." 

Mr.  Skey  {Operative  Sunienj,  p.  294)  preferred  the  posterior  incision 
for  these  reasons  :  (i)  It  is  a  part  less  liable  to  consequent  inflammation. 
(2)  The  requisite  separation  of  the  peritona3um  is  less  extensive.  (3)  The 
artery  is  brought  better  into  view,  the  act  of  passing  the  needle  round 
it  being  made  visible  to  observers  around.  (4)  The  line  of  the  vessel  is 
sufficiently  exposed  to  enable  the  operator  to  select  his  site  of  ligature, 
to  carry  it  either  higher  or  lower,  or  even,  if  necessary,  to  separate  the 
peritonaeum  from  the  aorta  itself,  and  to  pass  a  ligature  around  that 
vessel  at  a  sufficient  distance  from  its  bifurcation.  (5)  The  formation 
of  a  ventral  hernia  is  not  likely  to  occur. 

To  the  above  Mr.  Skey  might  have  added  that  the  posterior  incision 
gives  far  better  drainage  to  the  wound. 

The  diflB.culties  of  the  operation  and  the  causes  of  failure  and 
of  death  are  much  the  same  as  those  already  given  in  the  account  of 
ligature  of  the  external  iliac  (pp.  8-10). 

(3)  Intra-iJeriionceal  Method. — See  page  22. 


*  Sir  P.  Crampton's  operation  was  completed  in  twenty-two  minutes. 


LIGATURE  OF  THE  IXTEIIXAL   ILIAC.  19 


lilGATUEE    OF    THE    INTERNAL    ILIAC. 

Indications. — Very  few  and  rare. 

i.  In  some  cases  of  gluteal  and  sciatic  aneurj'snis. — Mr.  Holmes  in 
the  course  of  those  lectures  from  which  I  have  already  quoted,  lays  do^-n 
conclusions  which  will  very  greatly  help  the  surgeon  in  deciding  j\liat 
form  of  treatment  is  best  suited  to  these  aneurysms.  They  are  quoted 
below  under  the  heading  of  Ligature  of  the  Gluteal  Arter^'-  (p.  25). 

ii.  Ha3morrhage. — This  is  most  frequently  met  with  in  military 
surgery  after  gunshot  wounds  of  the  vessel  itself,  but  more  often  of 
one  or  more  of  its  branches  within  the  pelvis,  the  ball  entering  usually 
from  the  front  through  the  inguinal  region  or  behind  through  the 
sacrum. 

Four  such  cases  arc  given  by  Dr.  Otis,*  all  being  fatal.  Two  cases,  in  which  this  artery- 
was  tied  for  wounds  of  the  sciatic  and  gluteal  respectively,  are  given  by  the  above  writer 
(p.  332)  ;  both  were  fatal  from  hseniorrhage. 

Dr.  Liddelljt  who,  as  U.S.A.  Medical  Inspector,  saw  much  of  military 
surgery,  gives  the  following  advice  in  cases  of  punctured  wounds  of  this 
artery  or  its  branches  :  "  The  wound  should  be  explored  b}-  introducing 
the  finger  into  it  for  the  purpose  of  locating  bv  touch  the  precise  point 
whence  the  blood  issues  b}'  jets  into  the  wound.  If  the  punctured 
artery  is  found  to  be  external  to  the  pelvis,  the  bleeding  point  should 
be  laid  bare  by  enlarging  and  cleansing  the  wound,  and  the  vessel 
secured  by  ligatures  placed  on  each  side  of  the  ajDerture.  But  if  it  be 
shown,  by  the  occurrence  of  intra-pelvic  exti-avasation  of  blood,  or  by 
other  -signs,  that  the  internal  iliac  artery,  or  some  branch  thereof,  is 
wounded  within  the  pelvis,  it  will  be  impossible  to  reach  and  tie  the 
punctured  artery-,  in  the  wound.  Under  these  circumstances  it  some- 
times becomes  very  difficult  to  decide  what  plan  of  treatment  should  be 
adopted.  .  .  .  One  thing,"  Dr.  Liddell  goes  on  to  say,  "  ought  never  to 
be  done,  that  is,  trusting  to  the  use  of  iron  perchloride  or  iDersulphate.+ 
The  first  thing  to  be  tried,  in  most  cases,  is  compression.  It  should  be 
applied  to  the  common  iliac  artery,  and,  at  the  same  time,  to  the  wound 
itself,  if  possible,  with  a  view  to  obtain  coagulation  of  the  blood  in,  and 
obliteration  of,  the  wounded  artery.  The  very  desperateness  of  these 
cases  makes  it  all  the  more  necessary  to  use  the  compression  faithfully, 
intelligentl}^,  and  persistently,  otherwise  a  traumatic  aneurysm  will 
form."     No\A'ada}"s,  laparotomy  will  very  likeh*  be  resorted  to  (p.  22). 

iii.  To  bring  about  atrophy  of  the  enlarged  senile  prostate. 

Dr.  Bier,  first  assistant  to  Prof,  von  Esmarch,  of  Kiel,  was  the  first 
to  tie  the  internal  iliacs  for  the  above  purpose  (Wieu.  Klin.  Woch., 
No.  32,  Aug.  10,  1893). 

He  did  this  in  three  cases,  in  one  intra-periton;cally,  and  in  two  cxtra-peritonajally. 
The  latter  two  made  good  recoveries.  In  the  first  case  the  way  in  which  the  an;csthetic 
was  taken  caused  so  much  trouble  that,  Trendclenberg's  position  failing,  it  was  found 
needful  to  withdraw  a  large  part  of  the  small  intestine,  in  order  to  reach  the  arteries. 
This  patient  died  of  septic  peritonitis  on  the  third  day. 

*  Med.  and  Surg.  Hutonj  of  the  War  of  the  Rebellion,  pt.  ii.  p.  331. 
t  Intern.  En.eyel.  of  Surg.,  vol.  iii.  p.  125. 
%  Sec  the  remarks,  vol.  i.  p.  578. 


20  OPERATIONS  OX  THE  ABDOMEN. 

Dr.  W.  Me3'er  (Ann.  of  Simi.,  Jnlj  1894)  publishes  a  case  treated  hy 
Bier's  method. 

The  patient  was  55,  and  very  stout.  For  six  months  he  had  been  unable  to  pass  any 
urine,  having  to  rely  on  a  catheter  altogether.  The  prostate  was  generally  enlarged; 
its  upper  border  could  only  just  be  reached  per  recfiim.  The  extra-peritonasal  method 
was  adopted.  The  left  artery  was  taken  first.  An  incision,  slightly  concave  inwards, 
and  five  inches  long,  was  made  parallel  with  the  upper  third  of  Poupart's  ligament  and 
running  up  towards  the  tip  of  the  eleventh  rib.  The  common  and  internal  iliacs  were 
reached  without  much  trouble.  The  artery  was  tied  with  catgut,  but  the  vessel  having' 
been  punctured  when  the  sheath  was  divided,  two  ligatures  were  applied  on  either  side 
of  the  puncture,  and  the  artery  was  divided  between  them.  The  ligature  on  the  proximal 
end  slipped  off,  and  further  attempts  to  place  a  ligature  proving  futile,  a  long  pair  of 
artery  forceps  was  placed  on  each  divided  end,  and  left  in  fitu,  being  carefully  packed 
around  with  gauze.  The  right  internal  iliac  was  then  tied  with  a  double  catgut  ligature, 
but  the  vessel  was  not  divided.  The  two  forceps  were  removed  on  the  fifth  day,  no 
hasmorrhage  following.  On  the  twelfth  day  arterial  hemorrhage  took  place  from  the 
track  of  the  forceps  on  the  left  side.  On  opening  up  the  wound  it  was  found  that  the 
bleeding  came  from  an  opening  in  the  external  iliac,  due  to  the  pressure  of  the  f orceps^ 
where  it  crossed  this  vessel.  Pressure  being  made  on  the  common  iliac,  the  external  was 
tied  above  and  below  the  perforation,  and  then  the  common  iliac  was  tied  also,  silk  being 
used  on  this  occasion.  Partial  gangrene  of  the  foot  followed,  necessitating  an  irregular 
amputation  of  its  anterior  part.  The  influence  of  tying  both  internal  iliacs  in  the 
enlarged  prostate  in  this  interesting  case  was  as  follows :  Twelve  hours  after  the  opera- 
tion the  patient  began  to  pass  his  water  (twenty  ounces)  in  a  fine  stream  for  the  first  time 
for  six  months.  This  improvement  slowly  increased,  though  it  was  evident  that  there 
was  marked  atony  of  the  bladder.  The  patient  gained  sufficient  power  to  hold  his  water 
two,  or  even  three  or  four,  hours,  and  then  to  pass  ten  or  twelve  ounces  in  a  forcible 
stream.  The  residual  urine  remained  considerable,  ten  ounces  or  more.  The  prostate 
became  almost  normal  in  size,  and  the  length  of  the  urethra  became  reduced  from  23^ 
to  21^  cm.,  the  length  of  a  normal  urethra  being  21  cm. 

Dr.  Meyer  also  operated  according  to  this  plan  on  a  man,  aged  63,  with  retention 
due  to  hypertrophy  of  the  prostate.  A  single  silk  ligature  was  easily  placed  around 
each  artery  within  its  sheath,  and  tied.  The  wound  healed  without  reaction.  The 
patient  voided  his  urine  in  a  fine  forcible  stream  several  times  during  the  night 
after  the  operation.  Retention  did  not  again  set  in.  On  the  fifth  day  after  the 
operation  the  temperature  became  subnormal  without  apparent  cause,  and  the  patient 
died  comatose  three  days  later.  Only  a  very  limited  necropsy  was  permitted,  and  there 
is  no  account  of  the  state  of  the  kidneys. 

We  have  seen  that  the  two  cases  in  which  Dr.  Bier  operated  by  the  extra-peritonaeal 
method  recovered.  Neither,  before  the  operation,  had  been  able  to  pass  a  drop  of  urine. 
Spontaneous  power  returned  in  each  case,  and  improved  progressively,  one  of  the  patients- 
stating,  four  months  later,  that  he  could  micturate  as  well  as  ever  before. 

iv.  In  some  cases  of  vascular  pelvic  sarcoma,  and  inoi:)erable  uterine 
tumours  (Baudet  and  Kendirdjj^,  Ga^^.  des  Hojntavx^  April  i,  1899). 

V.  Also  as  a  prophylactic  against  haemorrhage  in  the  course  of  certain 
pelvic  operations,  such  as  abdominal  panhysterectomy,  and  in  abdomino- 
perinaeal  excision  of  the  cancerous  rectum  (Baudet  and  Kendirdjy,  loc. 
su^'a  cit.). 

Surgical  Anatomy. — A  short  trunk,  about  an  inch  and  a  half  long,, 
of  large  size,  the  internal  iliac,  given  off  opposite  to  the  lumbo-sacral 
intervertebral  disc,  dips  downwards  and  backwards  as  far  as  the  upper 
part  of  the  sacro-sciatic  notch,  where  it  gives  off  its  anterior  and  pos- 
terior trunks,  a  ligamentous  cord  also  coming  off  from  the  bifurcation: 
this  cord,  the  remains  of  the  obliterated  hypogastric  artery,  usually 
remains  pervious  as  far  as  tlie  bladder,  as  one  of  the  vesical  arteries. 


LIGATURE  OF  THE  INTERNAL  ILIAC.  21 

Line. — No  distinct  line  or  guide  can  be  given  for  this  vessel  owing  to 
its  at  once  dipping  into  the  pelvis,  but  it  will  be  worth  while  to 
remember  that  a  line  drawn  with  a  slight  curve  outwards  from  a  point 
about  an  inch  below  and  a  little  to  the  left  of  the  umbilicus,  to  the 
centre  of  Poupart's  ligament,  gives  sufficiently  accurately  the  line  of  the 
common  and  external  iliac  arteries :  the  intei-nal  is  given  off  about  two 
inches  fi'om  the  commencement  of  this  line.* 

Relations  : —  In  Front. 

Ureter. 
Peritonaeum. 
Rectum  (left  side). 
Outside.  Inside. 

Right  internal  iliac  vein.  Pyriformis. 

Obturator  nerve.  Sacral  nerves. 

Behind. 
Internal  iliac  vein. 
Sacro-iliac  synchondrosis. 
Lumbo-sacral  cord. 
Collateral  Circulation. 
Sciatic  with         Superior   branches    of    pro- 

funda. 
Htemorrhoidal  branches  ,,  Inferior  mesenteric. 

Pubic  branch  of  obturator  ,,  Vessel  of  opposite  side. 

Branches  of  pudic  ,,  Branches  of  opposite  vessel. 

Circumflex  and  perforating  of 

profunda  „  Sciatic  and  gluteal. 

Lateral  sacral  ,,  Middle  sacral. 

Circumflex  iliac  ,,  Ilio-lumbar  and  gluteal. 

Operation. — The  preparatory  treatment  being  the  same  as  in  ligature 
of  the  external  iliac  (p.  5),  the  surgeon  makes  an  incision  much  as  in 
the  case  of  the  common  iliac,  or  else,  in  the  words  of  Dr.  Stevens  (who 
iirst  tied  the  vessel  successfully  in  1812),  "one  about  five  inches  long, 
parallel  with  the  deep  epigastric  arter}^,  and  nearly  half  an  inch  on  the 
outer  side  of  it."  The  peritonseum  having  been  raised  up,  the  hips  are 
M'ell  flexed  and  the  lips  of  the  wound  retracted  as  %A'idely  as  possible  :  the 
finger  now  finds  the  external  iliac,  and  then,  by  tracing  it  up,  the  internal 
iliac  vessel. t  The  cord  of  the  obturator  nerve  must  not  be  mistaken 
for  this. I 

The  artery  is  now  separated,  partly  with  the  finger-nail  and  partly 
with  the  point  of  the  director,  and  the  needle  passed  from  within 
outwards,  avoiding  the  vein  and  psoas  muscle.  The  ureter  usually 
crosses  the  artery  at  its  commencement,  and  will  be  out  of  harm's  way. 
It  A\ill  be  well  to  have  in  readiness  aneurysm-needles  of  different  curves, 
and  an  ordinarj^  silver  eyed-probe. 

*  The  origin  of  tlie  arteries  will  be  found  nearly  opposite  to  the  centre  of  a  line  drawn 
from  the  anterior  superior  spine  to  the  umbilicus. 

t  The  finger  should  be  passed  downwards  and  backwards  towards  the  sacro-iliac 
synchondrosis. 

I  In  cases  of  doubt  the  artcrj'  should  be  compressed  gently  between  the  finger  and 
thumb. 


22  OPERATIONS  ON  THE  ABDOMEN. 

Ligature  of  the  Internal  and  other  Iliacs  by  Abdominal  Section. 

— This  method  has  been  advocated  recently  by  Dr.  Dennis,*  of  New 
York,  on  account  of  the  following  advantages: — (i)  Abdominal  section 
in  no  way  increases  the  dangers  of  the  operation  of  ligature  of  the 
internal  iliac.  (2)  This  method  prevents  a  series  of  accidents  which 
have  occurred  during  the  performance  of  the  operation  of  ligature  of 
this  artery  by  the  older  methods.  Amongst  these  are,  the  division  of 
the  circumflex  and  epigastric  arteries,  wounding  the  vas  deferens, 
including  the  ureter  in  the  ligature,  puncturing  the  iliac  or  circumflex 
veins,  tying  the  genital  branch  of  the  genito-crural,  tearing  the  peri- 
tonasum,  injury  to  the  sub-peritonaeal  connective  tissue,  cellulitis. 
(3)  Abdominal  section  enables  the  surgeon  to  apply  the  ligature  at 
a  point  of  election,  and  to  obtain  information  as  to  the  exact  extent  of 
the  disease  in  the  main  arterial  trunk.  (4)  Securing  the  internal  iliac  by 
this  method  takes  much  less  time  than  was  occupied  by  the  older  ones. 
Three  cases  are  given  by  Dr.  Dennis,  two  of  which  occurred  in  his 
own  practice : 

I.  A  woman,  aged  60,  presented  pulsatile  tumours  in  both  gluteal  regions,  the 
tumours  dating  back  a  year  and  a  half,  and  pain  three  years  back.  The  external  parts 
being  thoroughly  purified,  a  median  incision  was  made  from  the  umbilicus  to  the 
pubes  ;  the  small  intestines,  which  would  have  hindered  the  operation,  were  drawn  out 
into  warm  moist  sponges  and  towels,  the  internal  iliacs  of  both  sides  ligatured  with 
catgut,  the  viscera  returned,  the  woiind  closed,  and  aseptic  dressings  applied.  The 
patient  died,  with  suppression  of  urine  and  slight  parenchymatous  nephritis,  on  the 
third  day.  II.  A  negro,  aged  46,  had  a  right  gluteal  aneurysm,  the  trouble  dating  back 
seven  months.  By  a  curved  lateral  incision  the  abdomen  was  opened  ;  owing  to  the 
violent  efforts  of  the  patient,  and  the  ditliculty  of  manipulation,  a  few  coils  of  intestine 
were  drawn  out,  a  strong  silk  ligature  applied  to  the  internal  iliac,  the  parts  cleansed, 
and  the  wound  closed.  A  cure  followed.  III.  A  female,  aged  18,  had  an  aneurysmal 
varix  of  the  left  side,  the  trouble  dating  back  many  years.  Under  careful  antiseptic 
treatment  the  abdomen  was  opened,  the  incision  finally  extending  from  the  symphysis 
to  some  distance  above  the  umbilicus,  the  intestines  drawn  out  sufficiently  to  admit  of 
exposure  of  the  vessel,  a  double  twisted  catgut  ligature  applied  to  the  left  internal 
iliac,  the  bowels  returned,  and  the  wound  treated  as  before.  The  patient  rallied 
quickly,  and  the  bowels  were  moved  normally  on  the  fifth  day ;  a  slight  acute 
albuminuria,  due  to  congestion  of  the  kidney  from  the  ligature  of  the  main  trunk  of 
the  internal  iliac,  appeared  on  the  following  day,  but  soon  disappeared.  The  aneurysm, 
together  with  the  aneurysmal  varix,  was  perfectly  cured. 

A  few  cases  in  which  the  iliac  arteries  have  been  tied  intra-peri- 
tonosally  in  this  country  are  on  record.  One  of  the  most  interesting 
of  these  is  fully  recorded  by  Mr,  Makins  (Lancet,  vol,  ii.  1892,  p. 
1328). 

The  patient,  aged  30,  had  an  inguinal  aneurysm,  about  two  inches  in  breadth, 
extending  upwards  about  two-fifths  of  the  distance  between  the  middle  of  Poupart's 
ligament  and  the  umbilicus,  and  for  about  two  inches  below  the  ligament.  An  incision 
four  inches  long  was  made  in  the  left  linea  semilunaris ;  the  deep  epigastric,  which 
originated  in  the  swelling,  was  tied  between  two  ligatures.  The  small  intestines  were 
held  over  to  the  right  with  Messrs.  Ballance  and  Edmunds'  broad  abdominal  retractor, 
the  sigmoid  flexure  was  pushed  upwards,  and  an  incision  made  through  the  lower  part 
of  its  mesentery  and  the  peritonajum  at  the  margin  of  the  pelvis  in  the  course  of  the 
external  iliac.     The  wound  was  deep,  there  being  about  an  inch  and  a  half  of  subcu- 

*  Al'^r  York  Med.  A^'etvs,  Nov.  20,  1S86;  Annah  of  Surf/cry,  vol.  v.  No,  i,  p.  55.  I 
am  indebted  to  the  latter  periodical  for  the  above  account. 


LIGATUUE   OF  THE  INTEIiNAL  ILIAC.  23 

taneous  fat,  and  abundance  of  fat  in  the  sub-peritonaeal  tissue,  both  beneath  the  anterior 
abdominal  wall  and  around  the  vessel.  This,  together  with  some  retching,  rendered 
the  freeing  of  the  artery  and  the  passage  of  the  ligature  a  process  of  some  difficulty. 
The  spermatic  vessels  were  also  exposed  and  swelled  up  considerably  in  the  wound. 
The  artery  was  secured  about  three-quarters  of  an  inch  below  the  bifurcation  of  the 
common  iliac,  and  an  inch  and  a  half  above  the  sac.  Two  threads  of  stout  flossy 
sterilised  silk  were  tied  separately,  but  in  close  apposition,  and  with  sutlicient  tirmness 
to  rupture  the  internal  and  middle  coats.  The  posterior  peritonaeum  was  sutured  over 
the  artery.  The  patient  left  the  hospital,  with  the  aneurysm  hard,  painless,  and 
shrinking,  on  the  forty-seventh  day. 

The  following  remarks  from  Mr.  Makins,  ■well  known  not  only  as  a 
surgeon  but  also  as  an  anatomist,  I  quote  verbatim  : 

"  The  reason  for  selection  of  the  intra-peritonteal  method  in  this  case  was  the  high 
position  of  the  aneurysm.  Before  operation  the  pulsation  in  the  iliac  fossa  was  so 
forcible  and  extensive  that  it  seemed  probable  that  it  might  prove  necessary  to  ligature 
the  common  iliac,  and  it  was  thought  that  this  would  be  more  readily  performed  by  the 
intra-periton«al  method.  Beyond  this  the  intra-peritonteal  method  seemed  to  offer  the 
great  advantage  of  not  in  the  least  interfering  with  the  coverings  of  the  sac,  which,  by 
the  ordinary  method,  might  have  been  disturbed  by  the  stripping  of  the  peritonaeum. 
The  experience  gained  by  the  operation  showed  that  the  usual  method  might  have  been 
safely  adopted,  but  this  could  not  be  definitely  determined  beforehand.  An  advantage 
was  gained  in  ready  access  to  the  deep  epigastric  artery,  which,  as  directly  feeding  the 
sac  itself,  needed  ligature,  but,  of  course,  might  readily  have  been  secured  by  an  exten- 
sion of  the  ordinary  wound.  As  to  the  comparative  difficulty  of  the  two  operations  I 
think  there  is  little  to  choose,  and  on  the  whole  the  incision  for  the  extra-peritoneal 
method  is  perhaps  to  be  preferred  in  the  matter  of  cicatrix  ;  in  the  vertical  incision 
the  advantage  of  suturing  the  fibrous  structures  in  the  linea  semilunaris  is  gained  ; 
but,  on  the  other  hand,  the  resulting  cicatrix  passes  directly  through  from  skin  to 
peritonaeum.  In  the  oblique  incision  the  decussation  of  the  various  muscular  layers 
leads  to  a  certain  intricacy  and  irregularity  in  the  line  of  the  cicatrix  which  may 
render  it  the  stronger,  since  pressure  is  less  readily  brought  to  bear  directly  upon  it. 
The  choice  of  the  iliac  vessels  obtained  is,  I  think,  a  real  advantage,  since  the  incision 
needs  neither  extension  nor  modification ;  but  in  saying  this  it  should  be  pointed  out 
that  this  is  a  much  stronger  argument  on  the  right  than  on  the  left  side  of  the  body. 
Ligature  of  the  right  common  iliac  artery  by  the  intra-peritonteal  method  is  probably 
the  easiest  of  all  the  operations  on  the  great  arteries,  since  the  vessel  lies  directly 
beneath  the  peritonteum  of  the  posterior  abdominal  wall,  uncovered  by  any  structure 
of  importance.  On  the  left  side,  on  the  other  hand,  the  inferior  mesenteric  vessels  as 
they  enter  the  sigmoid  mesocolon  and  pass  down  to  the  mesorectum,  cover  practically 
the  whole  of  the  artery,  and  to  reach  the  common  iliac  comfortably  and  safely  the 
peritonasum  would  need  to  be  divided  close  to  the  left  of  the  median  line  of  the 
sacrum  and  displaced  outwards.  This  manoeuvre  has  the  disadvantage  of  exposing 
the  vein  freely,  but  this  would  probably  give  far  less  trouble  than  the  numerous 
mesenteric  vessels  would  when  swollen  by  reason  of  the  loss  of  their  peritoiuBal 
support.  In  the  case  recorded  above  the  distension  of  the  spermatic  vessels,  wheu 
set  free  by  the  division  of  the  peritoniBum,  was  much  greater  than  would  have  been 
expected." 

This  most  instructive  case  possesses  the  additional  and  especial 
interest  that  the  patient  developed  a  similar  aneurysm  on  the  right  side 
a  few  months  later  (Lancet,  vol.  ii.  1893,  p.  196), 

On  May  3,  1893,  Mr.  Makins  tied  the  right  external  iliac  intra-peritoiiffially.  An 
incision,  commencing  an  inch  below  the  level  of  the  umbilicus  and  four  inches  long, 
was  made  in  the  right  linea  semilunaris.  The  abdomen  being  opened,  the  small 
intestine  was  packed  away  with  two  small  sponges  and  tlie  posterior  wall  exposed. 
The  artery  was  then  seen  below  the  termination  of  the  ileum,  crossed  by  the  spermatic 
vessels.     The  aneurysmal  sac  was  about  an  inch  and  a  half  in  diameter.     The  peri- 


24  OPERATIONS  OX  THE  ABDOMEN. 

tonseum  over  the  artery  being  divided,  the  vessel  was  ligatured  with  two  strands  of 
floss  silk,  tied  with  separate  reef-knots,  and  then  the  peritongeum  sutured  over  the 
artery.  The  patient  was  kept  in  bed  for  two  weeks,  and  went  out  on  the  thirty-eighth 
day,  having  made  an  excellent  recovery.  A  firm  linear  scar  was  present  in  the  left 
linea  semilunaris,  and  two  small,  hard  swellings  marked  the  site  of  the  cured  aneurysms. 
Mr.  Makins  stated  that  he  repeated  the  trans-peritonaeal  method  here,  because  the  first 
had  proved  so  successful,  and  because  the  aneurysm,  though  small,  was  situated  entirely 
above  Poupart's  ligament.  The  operation  on  the  right  side  proved  much  easier  than 
that  on  the  left,  since  the  crossing  of  the  ileum  was  on  a  higher  level  than  was  the  case 
with  the  sigmoid  mesocolon.  The  artery  also  was  far  more  prominent  on  the  brim  of 
the  pelvis.  The  circulation  was  re-established  much  more  rapidly  and  satisfactorily 
after  the  second  than  after  the  first  operation.  On  the  first  occasion  the  limb  was  very 
cold,  and  the  patient  suffered  much  neuralgic  pain  ;  on  the  second  the  local  temperature 
fell  little,  if  at  all,  and  the  patient  had  no  pain.  On  the  first  occasion  the  deep  epigas- 
tric was  tied,  a  step  not  taken  on  the  second,  but  Mr.  Makins  was  inclined  to  think  that 
the  rapid  re-establishment  of  the  circulation  was  rather  dependent  on  the  enlargement 
of  the  branches  of  the  internal  iliac  on  the  opposite  side  resulting  from  the  obstruction 
of  the  first  external  iliac  artery. 

The  two  following  cases,  in  which  abdominal  section  was  resorted 
to  for  ligature  of  the  external  iliac,  show  a  striking  contrast  in  the 
difficulties  which  may  be  met  with  : 

In  Mr.  Mitchell-Banks'  case  QBrit.  Med.  Joiirn.,  vol.  ii.  1892,  p.  1163),  the  patient, 
aged  62,  had  an  ilio-femoral  aneurysm  as  big  as  a  fist  occupying  the  upper  part  of  the 
right  Scarpa's  triangle,  pushing  its  way  up  beneath  Poupart's  ligament.  On  September 
20,  1892,  the  abdominal  cavity  was  opened  by  an  incision  about  three  inches  long  in 
the  right  linea  semilunaris.  The  caecum  and  small  intestines  which  came  into  view  were 
held  apart  by  the  hands  of  an  assistant.  The  position  of  the  external  iliac  being  readily 
detected,  the  artery  was  tied  with  catgut,  .and  suSicient  pressure  used  to  stop  the 
pulsation  in  the  aneurysm,  and  no  more,  no  attempt  being  made  to  divide  the  internal 
coat.  The  incision  in  the  peritonjeum  immediately  over  the  artery  was  stitched  up  with 
fine  catgut,  so  as  to  make  the  artery  and  ligature  once  more  extra-peritonisal.  The 
patient's  recovery  was  uninterruptedly  successful,  save  for  one  incident.  On  the 
eleventh  day  the  sudden  onset  of  acute  praecordial  pain  and  cyanosis,  dyspnoea,  and 
collapse  were  thought  to  point  to  detachment  of  some  bit  of  clot  from  the  neighbour- 
hood of  the  ligature.  These  complications  gradually  disappeared.  For  some  time  the 
aneurysm  contained  fluid  at  one  part,  but  gradually  contracted,  and  the  patient  went 
out  on  the  forty-second  day  after  the  operation. 

Mr.  Banks  states  that  he  made  use  of  the  abdominal  section  here  because  the  aneurysm 
pu.shed  well  up  beneath  Poupart's  ligament,  and  he  could  not  make  out  with  certainty 
what  was  the  condition  of  the  artery  above  it. 

The  second  case,  under  the  care  of  Mr.  W.  H.  Brown,  of  Leeds,  tells 
a  very  different  story  of  the  difficulties  which  may  attend  ligature  of  the 
external  iliac  l^y  abdominal  section  : 

The  i)atient.  a  woman,  aged  48,  was  admitted  into  the  Leeds  General  Infirmary 
with  two  femoral  aneurysms.  The  upper  one,  the  size  of  a  large  cocoa-nut,  occupied  the 
right  groin,  extending  upwards  above  Poupart's  ligament ;  the  second,  a  smaller  one, 
•occupied  the  middle  third  of  the  same  right  femoral  vessel.  The  skin  over  the  upper 
swelling  was  dark,  very  thin,  and  threatening  to  give  way.  The  position  of  the  upper 
aueuiysm  was  thought  to  preclude  any  of  the  usual  operations,  and  it  was  decided  to  tie 
the  external  iliac  intra-periton:eally,  by  a  median  incision.  The  abdomen  was  opened 
by  an  incision  at  first  four  and  later  six  inches  long,  owing  to  the  great  amount  of  fat 
in  the  abdominal  wall.  The  omentum  was  also  very  thick  and  greatly  embarrassed 
manipulation.  It  was  only  after  the  pelvis  had  been  well  raised  and  emptied  of  the 
small  intestines  that  a  view  could  be  obtained  of  the  vessel.  Mr.  Brown  states  that  he 
had  the  greatest  difficulty  in  obtaining,  first  of  all,  a  view  of  the  vessel ;  secondly,  in 


LIC4ATURE  OF  THE  GLUTEAL  AIJTERY.  25 

passing  the  ligature.  So  far  as  the  abdominal  conditions  were  concerned  the  patient 
made  a  good  recovery,  but  the  foot  and  leg  becoming  gangrenous,  amputation  of  the 
thigh  became  necessary.  The  patient  sank  about  ten  weeks  after  the  ligature  of  the 
artery. 

Mr.  Wherry  {Lancet,  vol.  ii.  1893,  p.  136)  made  use  of  the  intra-peri- 
tonaeal  method  for  ligatm-e  of  the  left  internal  iliac  in  a  case  of  large 
pulsating  sarcoma  of  the  upper,  outer,  and  back  part  of  the  innominate 
bone.  The  swelling  was  too  large  and  vascular  to  admit  of  its  removal 
safely. 

"An  incision  was  made  from  below  the  umbilicus  to  the  pubes.  There  were  two 
difficulties.  Firstly,  the  vein,  which  was  very  large  and  much  in  the  way,  was  swollen 
by  the  slightest  pressure  of  sponges  or  retractors  upon  the  upper  part.  The  external  or 
common  iliac  would  have  been  much  easier  to  tie  in  this  case.  There  was  some  venous 
bleeding  which  stopped  after  the  artery  was  tied,  but  the  vein  also  was  tied  by  a  ligature 
just  below  the  first  one  to  make  it  safe.  The  other  difficulty  was  with  the  light. 
Large  reflecting  refractors  were  of  the  greatest  use,  but  an  electric  light  would  have  been 
better  still."  The  patient  made  a  good  recovery.  The  swelling  at  once  shrank  and 
ceased  to  pulsate,  and  the  relief  to  pain  and  other  distressing  symptoms  was  very  great, 
but  no  further  result  is  given. 

Mr.  Treves  {Operative  Surfjery,  vol.  i.  p.  213)  made  use  of  this  method  in  a  boy,  aged 
16,  with  a  vascular  tumour  of  the  buttock,  in  November  1889.  He  employed  an  incision 
irom  the  umbilicus  to  the  pubes,  and  kept  the  intestines  packed  up  and  aside  with 
six  sponges. 

The  following  is  Mr.  Treves'  opinion  of  the  merits  of  the  operation 
(loc.  siqyra  cit.,  p.  21 1),  and  he  is  inclined  to  extend  this  method  to  the 
comiuon  iliac  also:  "The  advantages  of  this  method  are  obvious.  The 
vessel  is  easih'  and  fully  exposed,  and  the  needle  can  be  passed  without 
risk  to  the  vein  or  ureter.  The  operation  is  simple,  and  involves  but 
little  time.  Its  dangers  are,  comparatively  speaking,  very  few.  The 
ligature  can  be  applied  accurately  at  the  spot  determined  upon.  The 
condition  of  the  artery  and  the  surrounding  parts  can  be  made  out.  and 
a  diagnosis  confirmed  or  modified.  The  great  objection  that  some  few 
3'ears  ago  would  have  been  urged  against  the  procedure — the  risk  of 
acute  peritonitis — may  be  at  the  present  daj^  almost  disregarded.'' 

Writing  as  I  do  for  those  whose  operative  experience  is  not  to  be  com- 
pared with  that  of  Mr.  Treves,  I  hesitate  to  endorse  the  above  opinion  in 
its  entirety.  I  am  of  opinion  that  with  the  above  incision  the  intestines 
will  sometimes  give  great  trouble.  A  good  deal  of  handling  and 
exposure  will  be  inevitable,  and  we  all  know  that  where  the  above  are 
entailed,  septic  peritonitis  does  still,  in  spite  of  the  advantages  of  modern 
surgery,  tend  to  appear.  In  fairness  I  must  add  that  I  have  onh'  once 
tied  either  of  the  iliac  vessels — the  common  iliac,  in  the  case  mentioned 
at  p.  14.  The  free  incision  there  made  use  of  would  have  rendered  the 
securing  of  the  internal  iliac  as  easy  as  it  did  that  of  the  parent  trunk. 
In  gunshot  injuries  or  stabs,  the  intra-peritona?al  method  will,  of  course, 
be  made  use  of.  My  readers  should  refer  to  Mr.  Makins'  opinion  on  the 
intra-peritongeal  method,  quoted  at  p.  22. 

LIGATURE    OF    THE    GLUTEAL    ARTERY. 

Indications. 

I.  Stab.  2.  Aneurj'sm.  3.  Hjemorrhage  after  opening  an  abscess. 
All  are  rare,  especially  the  last. 


26  OPERATIOXS  OX  THE  ABDOMEN. 

1 .  Stab. — The  source  of  the  bleeding  from  a  stab  in  tlie  buttock  mar 
be  very  difficult  to  tell  exactly.  The  surgeon  may  be  guided  by  the 
position  of  the  exit  of  the  gluteal  and  sciatic  vessels  (Fig.  6) ;  he  will 
remember  the  outline  of  the  gluteus  maximus,  the  lower  border  of  this 
mviscle  forming  the  fold  of  the  buttock,  the  upper  starting  from  the  crest 
about  two  inches  in  front  of  the  posterior  superior  spine,  and  running 
downwards  and  forw^ards  to  the  greater  trochanter.  Haemorrhage  from 
a  stab  in  the  upper  part  of  this  muscle  will  probably  come  from  the 
gluteal  ;  if  from  the  lower  part,  from  the  gluteal  or  sciatic. 

2.  Aneurysm. — This  affection  is  so  rare  that  it  will  be  sufficient  to 
quote  the  following  conclusions  of  Mr.  Holmes  :* 

(i)  "Gluteal  aneurysms,  both  traumatic  and  spontaneous,  are  very 
favourably  circumstanced  for  the  treatment  by  either  rapid  or  gradual 
compression  applied  to  the  aorta  or  common  iliac." 

Mr.  Holmes  points  out  that  gluteal  aneurysm,  if  not  ruptured,  is 
usuall}^  of  no  great  size,  and  does  not  encroach  upon  the  abdomen,  and 
thus  any  part  of  the  common  iliac  or  aorta  is  accessible  to  pressure. 

(2)  "If  this  treatment,  with  or  without  anassthetics,  does  not  succeed 
by  itself,  it  may  be  supplemented  by  coagulating  injection  or  gal  van  o- 
puncture,  while  the  patient  is  narcotised,  and  the  circulation  com- 
manded."    Of  the  two  Mr.  Holmes  prefers  galvano-puncture.f 

(3)  "When  such  treatment  fails,  and  particularly  in  aneurysms  with 
impei'fect  or  ruptured  sacs,  where  it  is  not  indicated,  the  internal  iliac 
must  be  tied  when  the  surgeon  thinks  that  he  cannot  find  the  artery 
outside  the  pelvis.  But  when  the  artery  is  accessible,  the  old  operation, 
or  the  operation  of  Anel,  should  be  practised,  according  to  the  size  and 
extent  of  the  tumour." 

In  deciding  whether  the  aneurysm  is  inside  or  outside  the  pelvis,  the 
surgeon  will  see  if  the  pulsation  can  be  commanded  by  pressure  on  the 
arter}'  above  the  aneurysm,  whether  the  latter  can  be  lifted  from  the 
bone,  and  will  also  make  an  examination  b}^  vagina  or  rectum.^ 

The  old  operation  must  always  be  formidable,  and  while  modern 
tourniquets  may  admit  of  efficient  pressure,  there  is  always  the  risk  of 
fatal  haemorrhage  from  the  artery  having  retracted  into  the  pelvis. 

The  method  of  Anel  does  not  seem  likely  to  be  often  useful :  of  three 
cases,  one  only  has  been  successful. 

(4)  "  The  ligature  of  the  internal  iliac  is  liable  to  failure  in  cases  of 
spontaneous  aneurysm  from  a  diseased  condition  of  the  coats  of  the 
artery,  and  should  always  be  avoided  when  other  means  of  treatment 
are  available." 

This  method  has  proved  fatal  in  about  half  the  cases  operated  on. 
The  varying  length  of  the  artery,  the  proximity  of  the  ligature  in  all 
cases  to  large  branches  and  to  the  sac,  have  all  to  be  remembered. 

Here  also  ligature  of  the  artery  by  laparotomy  will  probably  be  resorted 
to  in  the  future  (p.  22). 

Surgical  Anatomy  of  the  Gluteal  Artery. — A  short,  thick  branch 
from  the  posterior  division  of  the  internal  iliac,  this  leaves  the  pelvis 
above  the    pyriformis,   through  the    sacro-sciatic  notch.      Immediately 

*  Hunt.  Lect.,  Lancet,  1874,  vol.  ii.  p.  76 ;  Sy^t.  of  Sitrrj.,  vol.  iii.  p.  148. 
f  See   the  remarks  on   the   introduction   of  foreign   bodies   and   galvano-puncture, 
vol.  i.  pp.  644  and  648. 
%  An  anaesthetic  being  given,  and  the  hand  passed  here,  if  needful. 


LIGATURE  OF  THE   GLUTEAL  ARTERY.  27 

after  its  exit  it  divides  into  a  superficial  and  a  deep  portion.  The  super- 
ficial is  mainly  distributed  to  the  gluteus  maximus ;  the  deep  lies 
between  the  gluteus  medius  and  minimus,  and  divides  into  two,  the 
ui)per  branch  running  along  the  origin  of  the  gluteus  minimus,  and  the 
lower  running  obliquely  across  this  muscle  towards  the  trochanter  major. 
The  superior  gluteal  nerve  emerges  just  below  the  artery,  and  sends 
branches  with  the  deeper  portion. 

Line  and  Guide. — "If  a  line  be  drawn  from  the  posterior  superior 
spine  to  the  great  trochanter,  the  limb  being  slightly  tiexed  and  rotated 
inwards,  the  i)oint  of  emergence  of  the  gluteal  artery  from  the  upper 
part  of  the  sciatic  notch  will  correspond  with  the  junction  of  the  upper 
with  the  middle  third  of  this  line"  (MacCormac,  Lie/,  of  Arts.,  p.  126, 
Figs.  10,  II). 

Operation  (Fig.  6). — The  patient  being  rolled  two-thirds  over  on 
to  his  face,  the  part  well  exposed  and  cleansed,  the  limb  hanging  over 
the  edge  of  the  table,  an  incision,  five  inches  long,  is  made  in  a  line 
running  from  the  posterior  superior  spine  to  the  upper  and  inner  part 
of  the  great  trochanter.  The  incision  should  run  almost  parallel  with 
the  gluteus  maximus.  The  fibres  of  this  muscle  being  separated, 
between  adjacent  fasciculi,  with  a  director,  a  muscular  branch  should  be 
found  and  traced  down  to  the  exit  of  the  artery.  The  gluteus  maximus 
having  been  relaxed,  and  the  contiguous  margins  of  the  gluteus  medius 
and  pyriformis  sej^arated  with  retractors,  the  surgeon,  taking  as  his 
guide  the  above  line  and  the  aperture  of  the  great  sacro-sciatic  notch, 
clears  the  artery  as  high  up  as  possible,  avoiding  the  nerve  and  the 
veins,  and  dividing  the  adjacent  muscles  if  needful.  The  ligature  should 
be  applied  as  far  within  the  notch  as  possible,  almost  within  the  pelvis, 
as  the  artery  divides  immediately  after  its  exit. 

Old  Operation. — The  following  is  the  account  of  Prof.  Syme's  case. 
The  man  had  been  stabbed  in  the  buttock  seven  years  before.  The 
aneurysm  measured  more  than  13  inches  in  both  diameters;  this, 
together  with  the  great  thinness  and  laxity  of  the  coverings  l)eing 
opposed  to  coagulation,  led  to  the  adoption  of  the  old  operation. 

'•  The  patient  having  been  rendered  unconscious  and  placed  on  his  right  side,  I  thrust 
a  bistoury  into  the  tumour,  over  the  situation  of  the  gluteal  artery,  and  introduced  my 
finger  so  as  to  prevent  the  blood  from  flowing,  except  by  occasional  gushes  which  showed 
what  would  have  been  the  effect  of  neglecting  this  precaution,  while  I  searched  for  the 
vessel.  Finding  it  impossible  to  accomplish  the  object  in  this  way,  I  enlarged  the 
wound  sufficiently  for  the  introduction  of  my  fingers  in  succession,  until  the  whole  hand 
was  admitted  into  the  cavity,  of  which  the  orifice  was  stiU  so  small  as  to  embrace  the 
wrist  with  a  tightness  that  prevented  any  continuous  haemorrhage.  Being  now  able  to 
explore  the  state  of  things  satisfactorily,  I  found  that  there  was  a  large  mass  of  dense 
fibrinous  coagulum  firmly  impacted  into  the  sciatic  notch,  and.  not  without  using  con- 
siderable force,  succeeded  in  disengaging  the  whole  of  this  obstacle  to  reaching  the 

artery The  gentleman  who  assisted  me  being  prepared  for  the  next  step  of  the 

process,  I  ran  my  knife  rapidly  through  the  whole  extent  of  the  tumour,  turned  out  all 
that  was  within  it,  and  had  the  bleeding  orifice  instantly  under  subjection  by  the 
pressure  of  a  finger.  Nothing  then  remained  but  to  pass  a  double  thread  under  the 
vessel  and  tie  it  on  both  sieics  of  the  aperture."  The  case  did  perfectly  well.*  (Obf.  in 
Clin.  Sunj.,  p.  169.) 

*  Nowadays  the  application  of  a  Lister's  tourniquet  to  the  abdominal  aorta  would 

facilitate  matters.  Another  successful  case  is  recorded  by  Mr.  J.  Bell,  Prtn.  0/  Surg., 
vol.  i.  p.  1801. 


28 


OPEKATIONS  ON  THE   ABDOMEN. 


If,  in  the  case  of  a  stab,  the  hcemorrhage  continues  after  the  ligature 
has  been  applied  with  the  above  precautions,  and  the  gluteal  has  evi- 
dently been  punctured  within  the  pelvis,  the  internal  iliac  must  be  tied 
after  the  wound  in  the  buttock  has  been  firmly  plugged  with  iodoform 
gauze  MTung  out  of  carbolic  acid  (i  in  20). 


Fig.  6. 


Position  and  direction  of  the  superficial  incisions  which  must  be  made  to  secure 
the  gluteal,  sciatic,  or  x^udic  arteries. 

A.  Posterior  superior  iliac  spine.  C.  Tuberosity  of  ischium. 

B.  Great  trochanter.  D.  Anterior  superior  iliac  spine. 

AB.  Ilio-trochanteric  line,  divided  into  thirds.  This  line  corresponds  in  direc- 
tion with  the  line  of  the  fibres  of  the  gluteus  maximus.  The  incision  to  reach  the 
gluteal  artery  is  indicated  by  the  darker  portion  of  the  line.  Its  centre  is  at  the 
junction  of  the  upper  and  middle  thirds  of  the  ilio-trochanteric  Hue,  and  exactly 
corresxjonds  with  the  point  of  emergence  of  the  gluteal  artery  from  the  great  sciatic 
notch. 

AC.  Ilio-ischiatic  line.  The  incision  to  reach  the  sciatic  or  internal  pudic  arteries 
is  indicated  by  the  lower  dark  line.  It  is  also  to  be  made  in  the  direction  of  the 
fibres  of  the  gluteus  maximus.  The  centre  of  the  wound  corresponds  to  the 
junction  of  the  lower  and  middle  thirds  of  the  ilio-ischiatic  line.     (Mac  Cormac.) 

Macewen's  Method  (vol.  i.  p.  645). — A  case  thus  treated  successfully 
in  the  Edinburgh  Infirmar}^  by  Mr.  Miller  is  recorded  (Brit.  Med.  Journ., 
1893,  vol.  i.  p.  1 176)  : 

The  patient  here  was  aged  75  on  June  i.  1891.  The  surface  of  the  swelling  having 
been  well  cleansed,  six  long  aseptic  steel  pins  were  introduced  into  the  sac  in  different 
directions,  and  made  to  pass  through  it  until  they  were  felt  to  impinge  against  the 


LIGATURE   OF  THE   ABDOMIXAL  AORTA.  29 

opposite  -wall.  They  were  then  withdrawn  a  little  so  that  their  points  might  scratch  the 
inner  surface  of  the  cavity.  The  pulsations  of  the  swelling  were  sufficiently  powerful 
to  move  the  points  of  the  pins,  and  to  cause  them  to  irritate  the  internal  wall  of  the 
aneurysm.  They  were  left  in  about  half  an  hour,  and  when  withdrawn  the  punctures 
were  covered  with  collodion.  No  anaesthetic  was  given,  nor  did  the  patient  complain  of 
much  pain.  On  June  12  the  above  treatment  was  repeated,  only  four  pins  being  used 
now :  since  two  of  those  used  before  were  found  to  be  too  fine  on  this  occasion,  as  they  bent 
when  force  was  used  to  make  them  perforate  the  now  thickened  wall  of  the  aneurysm. 
On  June  25  no  pulsation  could  be  detected  in  the  aneurysm,  which  had  shrunk  consider, 
ably.  At  this  date  a  pulsating  swelling  was  felt  between  the  xipho-stemuni  and 
umbilicus.  July  10,  the  gluteal  aneurysm  was  quite  firm  to  the  touch.  The  abdo- 
minal swelling  increased  rapidly.  At  first  it  was  thought  to  be  another  aneurysm,  but 
it  was  later  diagnosed  as  malignant,  the  pulsation  of  the  aorta  being  transmitted 
through  it.  The  patient  sank  on  August  30.  At  the  necropsy  a  large  soft  sarcoma  was 
found  infiltrating  the  upper  part  of  the  abdomen.  The  gluteal  aneurysm  was  found  to 
be  quite  firm  and  solid.  It  was  mostly  filled  with  firm  fibrous  clot,  a  small  part  in  the 
centre  being  softer. 


LIGATURE    OF    THE    SCIATIC    ARTERY. 

Indications. — Stab.  This  operation  is  so  rarely  required  tliat  it  may 
be  very  briefly  described  here. 

Surgical  Anatomy. — The  sciatic  artery  emerges,  together  with  the 
sciatic  nerve  and  the  pudic  arter\",  from  the  lower  part  of  the  great 
sacro-sciatic  notch  below  the  pyriformis. 

Guide  and  Line. — The  limb  being  rotated  inwards,  a  line  is  dra\\-n 
from  the  posterior  superior  spine  to  the  ischial  tuberosity.  The  exit  of 
the  sciatic  and  pudic  arteries  corresponds  to  the  junction  of  the  middle 
and  lower  thirds  of  this  line. 

Operation  (Fig.  6). — The  sciatic  artery  may  be  found  by  one  of  two 
incisions — ('/)  by  a  horizontal  one,  about  five  inches  long,  made  about 
an  inch  and  a  half  below  that  for  the  gluteal  artery,  and,  like  that, 
parallel  with  the  fibres  of  the  gluteus  maximus ;  (h)  by  one  made 
vertically  in  the  above  given  line.  The  deeper  guides  will  be  the 
margins  of  the  notches,  or  the  great  sciatic  nerve. 


LIGATURE    OF    THE    ABDOMINAL    AORTA. 

Indications. — As  this  most  rare  operation  has  been  fatal  in  every  one 
of  the  cases  in  which  it  has  been  performed  (some  nine  or  ten),  its  justi- 
fiability has  naturally  been  called  in  question.  On  the  one  hand,  the 
desperate  condition  of  the  patients,  the  advanced  amount  of  disease 
probabl}-  present  in  their  arteries,  hearts,  &c.,  the  large  and  rapid  blood- 
current,  the  disturbance  of  veiy  A-ital  parts,  and  the  risk  of  peritonitis, 
all  combine  to  render  the  probability  of  success  extremely  small.  On 
the  other  hand,  recent  improvements  in  surgery,  the  introduction  of 
better  ligatures,  the  fact  that  in  these  cases  life  must  speedily  end  if 
nothing  be  done,  and,  perhaps,  the  fact  that  many  of  the  major  operations 
of  surgery  have  been  unsuccessful  at  first,  will  justify  surgeons  in  again 
making  trial  of  this  forlorn  hope,  if  they  feel  certain  that,  otherwise,  the 
case  is  quite  hopeless. 

The  cases  have  mostly  been  those  of  iliac  and  inguinal  aneurysm  in 


30  OPERATIONS  OX  THE  ABDOMEX. 

which  other  arteries  have  been  tied  without  success.  To  justify  the 
epithet  above  gi\-en  of  "  desperate,"  the  first  case,  the  well-known  one 
of  Sir  A.  Cooper  (in  1817),*  naay  be  alluded  to. 

Here  the  patient  had  long  suffered  from  an  aneurysm  affecting  the  external  and 
common  iliac  arteries,  leading  to  sloughing  of  the  skin  and  hiemorrhage.  Sir  Astley 
having  failed  in  an  attempt  to  perform  the  old  operation,  owing  to  the  artery  lying  so 
deeply,  gave  the  patient  "  the  only  hope  of  safety  "  which  remained,  by  tying  the 
aorta. 

As  life  was  here  prolonged  for  forty  hours,  and  as  in  Monteiro's 
case  death  did  not  take  place  till  the  tenth  day,  proof  is  given  of  the 
restoration  of  the  collateral  circulation.! 

Mr.  Mitchell  Banks  records  briefly  (Brit.  Med.  Journ.,  1892,  vol.  ii. 
p.    1 164)  the  following  most  interesting  case: 

About  fifteen  years  before,  a  patient  in  a  state  of  exhaustion  came  under  his  care 
with  a  rapidly  increasing  aneurysmal  swelling  occupying  the  left  iliac  region,  and 
reaching  to  the  middle  line  in  front  and  to  the  umbilicus  above.  '•  It  was  impossible  to 
say  where  it  sprang  from,  but,  as  the  man  evidently  had  only  a  short  time  to  live,  it 
was  necessary  to  act  promptly.  I  opened  the  abdomen  in  the  middle  line  (which  was 
thought  rather  an  adventurous  proceeding  in  those  days),  with  the  intention  of  tying  the 
common  iliac,  or  the  aorta  itself,  if  I  got  a  chance.  But  it  was  found  impossible  to  do 
anything.  The  aneurysm  overla])ped  the  left  common  iliac  and  the  lower  portion  of  the 
aorta,  so  that  neither  of  them  could  be  reached.  It  was  a  gigantic  thing,  and  had  been 
leaking  for  some  time  at  the  back,  tearing  up  the  tissues  behind  the  peritonaaum  in  all 
directions."     The  patient  sank  a  few  days  later.     No  necropsy  is  mentioned. 

In  addition  to  the  above  cases,  in  which  the  aorta  has  been  tied  in  cases  of  aneurysm, 
it  has  been  tied  once  for  haemorrhage  after  a  gunshot  injury  of  the  upper  part  of  the 
thigh,  by  Czerny,  of  Heidelberg.  Haemorrhage  continuing,  the  common  femoral  was  tied, 
together  with  the  superficial  femoral  below  the  profunda.  Bleeding  taking  place  again  in 
six  days,  the  common  iliac  was  tied.  The  hsemorrhage  still  persisting,  it  was  thought  that 
the  external  iliac  only  had  been  tied,  and  a  ligature  was  next  placed,  by  mistake,  upon 
the  aorta.  The  patient  lived  twenty-six  hours.  The  same  surgeon  during  a  nephrec- 
tomy for  a  soft  malignant  groNvth  of  the  kidney  met  with  such  uncontrollable  haemor- 
rhage as  to  compel  him  to  tie  the  aorta,  the  patient  dying  soon  after. 

Surgical  Anatomy. — The  lowest  part  of  the  aorta — viz.,  that  between 
the  bifurcation  and  the  origin  of  the  inferior  mesenteric — is  that  which 
should  be  chosen. ;[: 

The  vessel  may  have  in  front  of  it  the  omentum,  duodenum,  mesentery, 
small  intestines,  and,  more  closely,  the  aortic  plexus  of  the  sympathetic, 
and  a  layer  of  fascia  of  various  strength.  To  the  right  side  lies  the  vena 
cava,  and  behind  it  are  the  left  lumbar  veins.  The  bifurcation  is  usually 
situated  a  little  to  the  left  side  of  the  umbilicus  and  about  three- 
quarters  of  an  inch  below  it. 

*  Prin.  and  Pract.  of  Surg,  (edited  by  Dr.  Lee),  vol.  i.  p.  228. 

•f  In  comparing  instances  of  the  restoration  of  the  circulation,  the  one  by  disease  and 
the  other  after  the  surgeon's  ligature,  the  importance  of  the  slow  and  gradual  process  in 
the  one  case  will  not  be  lost  sight  of.  Mr.  Barwell  {Iniern.  Encyd.  of  Surg.,  vol.  iii. 
p.  481)  alludes  to  the  experiments  of  Pirogoff  (AValler  and  von  Griife's  Journ.,  Bd.  xxvii. 
S.  122)  and  a  paper  by  Kast  (^Zeit.  f.  Chir.,  Bd.  xii.  S.  405)  to  show  that  the  collateral 
circulation  is  established.  Sir  A.  Cooper  (Jor.  supra  fit.')  used  to  show  in  his  lectures  an 
injected  specimen  from  a  dog  which  survived  the  operation.  Beyond  this  fact,  however 
no  comparison  can  be  made  between  the  chance  of  survival  of  healthy  animals  and  that 
of  patients  reduced  to  such  straits  as  to  call  for  this  operation. 

X  This  interval  varies  in  length  from  half  an  inch  to  two  inches. 


LIGATURE   OF  THE  ABDOMINAL  AORTA.  31 

Operation. — This  may  be  performed  (A)  through,  or  (B)  behind,  the 
peritonanini.  The  intra-peritunseal  method  is  especially  indicated  when 
the  height  at  which  the  ligature  must  be  applied,  or  any  evidence  of 
matting  of  the  structures  of  the  abdominal  wall  (dating  to  inflam- 
mation about  the  aneurysm,  or  to  the  use  of  pressure),  would  probablj* 
interfere  \\'ith  stripping  up  the  peritonaeum. 

A.  Through  the  Peritonceuni. — The  bowels  having  been  emptied  as 
much  as  possible,  the  skin  cleansed,  the  shoulders  raised,  and  the  knees 
slightly  fl.exed,  the  surgeon  makes  an  incision  at  least  four  inches  long, 
in  the  middle  line,  with  its  centre  opposite  to  the  umbilicus,  but 
curving  a  little  to  the  left  here,  so  as  to  avoid  the  round  ligament  of  the 
liver  and  the  urachus.  The  linea  alba  being  found  and  divided,  the 
fascia  transversalis  slit  up,  all  haemoiThage  must  be  arrested  before 
opening  the  peritonaeum.*  When  this  structure  has  been  opened  to  the 
whole  extent  of  the  wound,  retractors  are  inserted,  and  the  small  intes- 
tine and  mesentery  drawn  partly  upwards  and  partly  to  the  sides, 
carbolised  sponges,  attached  to  silk,  being  packed  around,  if  needful, 
to  keep  the  above  structures  out  of  the  way.  The  pulsation  of  the  vessel 
is  now  felt  for,  and  the  deeper  layer  of  peritongeum  carefully  scratched 
throiigh.  Care  should  be  taken  to  disturb  as  little  as  possible  the  aortic 
plexus  t  during  this  step  and  in  passing  the  needle,  which  should  be 
carried  from  right  to  left. 

The  ligature  used  should  be  one  of  the  flat  tape-like  ones,  of  kangaroo 
tendon  or  sufiiciently  stout  silk.  The  passage  of  the  needle  may  be 
attended  with  mvich  difiiculty,^:  not  only  from  the  depth  of  the  vessel, 
and  from  the  presence  of  intestines  if  distended  and  allowed  to  protrude 
into  the  wound,  but  also  from  the  denseness  of  the  cellular  tissue 
surrounding  the  artery. 

B.  BeJiind  the  Per  it  once  urn  (Fig.  5). — This  method  should  be  tried 
in  any  case  where  the  surgeon  is  unable  to  take  those  precautions  for 
which  intra-peritonffial  surgery  calls.  The  chief  objection  is  the  great 
depth  at  which  the  artery  is  reached ;  but  it  is  well  worthy  of  notice 
that  in  Monteiro's  case,  which  survived  ten  days,  this  method  was  made 
use  of. 

The  operation  is  performed  on  much  the  same  lines  as  that  already 
given  for  ligature  of  the  common  iliac  (p.  17).  The  incision  should  be 
as  free  as  possible,  from  the  tip  of  the  tenth  rib,  curving  somewhat 
forwards  to  the  anterior  superior  spine.§     The  muscles  and  transversalis 

*  In  Mr.  James's  case  (^Med.-CMr.  Irons.,  vol.  xvi.  p.  10)  a  large  quantity  of  blood 
was  found  post-mortem  in  the  abdominal  cavity.  This  had  come  either  from  a  vessel  in 
the  parietes,  or  from  one  wounded  in  the  mesentery. 

f  Sir  A.  Cooper  (Joe.  snpra  cit.')  believed  that  his  experiments  on  dogs  proved  that 
inclusion  of  this  plexus,  and  not  the  interruption  of  the  circulation,  was  the  cause  of 
the  paralysis  which  followed  the  experimeut.  In  Mr.  James's  case,  when  the  ligature 
was  tightened,  the  patient  complained  of  '•  deadness  in  the  lower  extremities."  This 
was  soon  followed  by  agonising  pain  in  the  same  parts,  only  relieved  by  death  about 
three  hours  after  the  operation. 

X  Thus,  in  Mr.  James's  case  the  aneurysm-needle  broke  at  its  handle,  the  surgeon 
having  "  little  anticipated  occasion  for  so  much  force."  In  one  case  the  sac  gave  way 
during  the  operation. 

y*^  If  necessary,  a  horizontal  one  might  be  added,  at  right  angles  to  the  first,  but  the 
rectus  and  the  deep  epigastric  should  on  no  account  bo  interfered  with. 


32  OPERATIONS  ON  THE  ABDOMEN. 

fascia,  being  ciit  through,  the  peritonaeum  is  stripped  up  and  turned 
inwards,  several  large  retractors  placed  in  the  wound,  and  the  ribs 
dragged  up  and  outwards.  The  common  iliac  being  found,  this  vessel 
is  traced  up  into  the  aorta  (Fig.  5). 

Treatment  by  Acupuncture. — This  method  has  been  fully  alluded  to 
at  p.  645,  vol.  i. ;  and  a  brilliantl}^  successful  case  of  abdominal  aneurysm 
treated  b}^  Prof.  Mace  wen  with  needles,  and  the  formation  of  white 
thrombi,  will  be  found  at  p.  647.  vol.  i. 

Treatment  by  the  Introduction  of  Wire. — This  method  has  been 
described  at  p.  644.  vol.  i.  Prof.  Loreta,  of  Bologna,  has  applied  it  to  one 
case  of  abdominal  aneurysm  which  attracted  much  attention  at  the  time, 
but  proved,  as  is  so  common  in  these  cases,  only  temporarily  successful. 
An  account  wall  be  found  (Brit.  Med.  Journ.,  vol.  i.  1885,  pp.  745,  955), 
taken  from  the  original  paper  (Mem.  Eoy.  Acad.  Scien.  Institute  of 
Bologna,  Feb.  8,   1885). 

The  patient  was  a  sailor,  aged  30,  who  had  always  had  good  health,  save  for 
syphilis  five  years  before.  Nearly  two  years  before  his  admission  he  had  felt  something 
give  way  in  the  belly  while  making  violent  efforts.  A  large  aneurysm  occupied  the 
epigastric  and  left  hypochondriac  regions.  An  incision  having  been  made  from  the 
ensiforra  cartilage  to  the  umbilicus,  numerous  superficial  adhesions  were  found,  and 
carefully  separated,  but  it  was  found  impossible  thus  to  deal  with  deeper  ones  uniting 
the  sac  to  the  stomach,  spleen,  and  diaphragm.  Hence  it  was  impossible  to  trace  the 
aneurysm  to  its  mouth,  nor  could  it  be  compressed  and  emptied.  It  remained  uncertain, 
therefore,  at  the  time,  whether  the  aorta  or  one  of  its  branches  was  the  vessel  involved. 
The  vessel,  which  was  now  fully  exposed  on  its  right  side,  was  punctured  with  a  fine 
trocar,  and  silvered  copper  wire  passed  in  from  above  downwards  and  to  the  left.  As 
soon  as  the  wire  met  resistance  the  cannula  was  removed,  the  end  of  the  wire  pushed 
in,  and  the  puncture  brushed  over  with  pure  carbolic  acid.  A  little  over  two  yards  had 
been  introduced.  The  after-course  was  one  of  rapid  and  progressive  recovery.  The 
man  was  allowed  to  get  up  at  the  end  of  six  weeks,  the  swelling  having  consolidated, 
the  bruit  having  disappeared,  the  pulsation  being  only  communicated,  and  the  femoral 
pulse,  which  had  been  almost  suppressed,  having  reappeared.  The  patient  died 
suddenly,  ninety-two  days  after  the  operation,  from  rupture  of  the  aorta  immediately 
below  the  sac  at  the  angle  of  juncture  between  this  and  the  aorta.  The  sac,  filled  with 
organising  fibrin,  had  shrunk  to  the  size  of  a  walnut.  The  wire  was  found  unaltered 
and  rolled  up  in  a  globular  mass.  Prof.  Loreta  suggested  that  the  compression  pro- 
duced by  the  coagula  in  the  sac  might  have  caused  an  interference  with  the  blood- 
supply  to  the  arterial  wall  just  below  the  swelling,  and  so  induced  rupture  of  an  arteiy 
no  doubt  already  diseased. 

Treatment  by  Temporary  Compression. — Prof.  Keen  (Amer.  Journ. 
of  Med.  8ci.,  Sept.  1900),  who  publishes  a  case  of  ligature  of  the  abdominal 
aorta  just  below  the  diaphragm,  the  patient  surviving  forty-eight  days, 
has  devised  an  instrument  by  means  of  which  temporary  compression  of 
the  aorta  may  be  carried  out.  The  instrument,  which  is  fully  described 
and  figured,  consists  of  a  screw  clamp  in  two  parts,  which  is  applied 
directl}'  to  the  aorta  through  an  opening  in  the  abdominal  wall. 

Four  experiments  on  dogs  are  described,  the  results  of  which  clearly 
show  the  feasibility  of  the  plan. 

Prof.  Keen  considers  that  the  instrument  might  be  used  either  for  a 
short  interval  under  anesthesia,  or  might  be  left  in  sittt  for  two  or  three 
days,  during  which  pressure  could  be  applied  at  intervals. 


CHAPTER  11. 
OPERATIONS  ON  HERNIA.* 

OPERATIONS  FOR  STRANGULATED   HERNIA.— RADICAL 
CURE  OF  HERNIA. 

OPERATIONS  FOR  STRANGULATED  HERNIA. 

Chief  Indications  for  Operation  and  Points  to  bear  in  Mind. — While 
this  is  not  the  place  for  going  into  the  above  fully,  a  few  practical 
remarks  on  those  indications  usually  given  may  be  helpful  to  some  of 
my  readers. 

i.  A  lump  in  one  of  the  openings,  more  or  less  hard,  tense,  and  tender, 
partly  or  completely  irreducible,  and  with  im2:)ulse  doubtful  or  absent. 

a.  The  swelling  may  be  small  and  deep-seated,  as  in  a  bubonocele 
tiear  the  internal  ring,  or  a  femoral  hernia  in  a  fat  patient. 

h.  Two  herniee  may  be  present,  both  irreducible.  The  surgeon  should 
■operate  on  the  one  which  is  the  more  tense  and  has  the  less  impulse,  and 
the  one  A\'hich  has  the  more  recently  descended.  If  this  fail  to  o-ive 
relief,  either  the  opposite  swelling  must  be  explored  or  abdominal 
section  performed  in  the  middle  line.  This  step  will  probably  allow  of 
the  opposite  hernia  being  reduced  from  within,  and  also  of  any  other 
possible  seats  of  strangulation  being  exj^lored — viz.,  the  inner  aspects  of 
the  deeper  rings. 

c.  As  to  the  impulse,  it  is  worth  while  to  observe  carefully  the  point 
■where  this  ceases.  This,  probably,  is  over  the  site  of  stricture,  and 
:should  be  about  the  centre  of  the  incision. 

On  this  most  important  point,  of  impulse,  Sir.  W.  H.  Bennett  speaks 
as  follows  :  In  a  case  of  strangulated  omental  inguinal  hernia  with 
commencing  gangrene  of  the  omentum,  there  yet  was  no  interfei'ence 
with  the  action  of  the  bowels,  constipation  and  vomiting  were  alike 
entirely  absent,  but  the  symptom  which  conclusively  called  for  opera- 
tion was  the  entire  absence  of  real  hernial  impulse.  The  following 
remarks  on  the  detection  of  impulse  are  worthv  of  the  most  careful 
attention :  "  The  impulse  in  ordinary  non-strangulated  hernia,  whether 
the  contents  of  the  sac  be  omentum  or  bowel,  is  expansile  in  character, 
that  is  to  say,  the  tumour,  when  the  patient  coughs  or  strains,  not  only 

*  The  diiferent  forms  of  heruia,  those  which  present  on  the  thigh  as  well  as  the 
inguinal  and  umbilical  varieties,  will  be  considered  here  for  the  sake  of  couveuieuce, 
.and  because  they  are  all  abdominal  in  origin. 

VOL.    II.  :i 


34  OPERATIOXS  OX  THE  ABDOMEX. 

rises  under  the  hand,  but  expands  in  size.  In  hernial  tumours  con- 
taining bowel  this  sudden  increase  in  the  bulk  is  principally  due  ta 
the  additional  quantity  of  gas,  &c.,  which  is  suddenly  driven  into  the 
herniated  portion  of  gut  by  the  act  of  coughing  or  straining.  In 
omental  herni^e  the  expansion  is  partly  due  to  the  sudden  turgescence 
in  the  omental  vessels,  and  partly  to  the  increase  of  tension  in  the  sac 
due  to  the  cough.  Naturally,  therefore,  the  amount  of  expansion  is 
relatively  greater  in  hernise  containing  bowel  than  in  those  composed  of 

omentum In  strangulated  hernia  it  is  important  to  understand 

that  absence  of  impulse  does  not  necessarily  mean  immohiliti/  diiring^ 
coughing,  for  a  hernia,  even  if  tightly  strangulated,  will  often  move 
freely  under  the  hand,  especially  if  it  be  omental.  This  movement  is, 
however,  rather  of  the  nature  of  a  jump  or  jerk,  and  is  never  expansile. 
There  is  no  question  which  has  a  more  practical  bearing  upon  the  treat- 
ment of  strangulated  hernia  than  the  expansile  character  of  this  impulse. 
It  ma}'  be  safely  held  as  a  surgical  dictum,  that  ecery  case  of  Jiernia  in 
tchich  any  change  has  tahen  place  in  the  condition  of  the  tumour,  s%ich  as: 
increase  of  size  or  tension,  vhilst  expansile  impulse  is  ahsent,  should  he 
regarded,  as  strangulated.^ 

d.  Sir  J.  Paget  (Clin.  Led.,  p.  io8)  thus  wrote  of  the  hardness  of  a 
hernia;^" In  large  hernias  the  hardness  may  chiefly  be  felt  at  and  near 
the  neck  and  mouth  of  the  sac,  especiallv  in  ingi^inal  hernife,  and  you 
miast  take  care  not  to  be  deceived  by  a  sac  A\-hich  is  soft  and  flaccid 
everywhere  except  at  its  mouth,  for  there  may  be  strangulated  intestine 
in  the  mouth  of  the  sac  though  the  rest  contain  only  soft  omentum  or 
fluid  not  sufficient  to  distend  it ;  nay,  you  must  not  let  even  a  wholly 
soft  condition  of  the  hernia,  or  an  open  external  ring,  weigh  down 
against  the  well-marked  symptoms  of  strangulation,  for  the  piece  of 
intestine  at  the  mouth  of  the  sac  may  be  too  small  to  give  a  sensation 
of  hardness,  or  the  whole  hernia  may  be  omental."' 

ii.  Constipation  becoming  absolute,  even  as  to  flatus. — It  is  well 
known  that  small  scybalous  motions  may  be  forced  out  by  the  straining 
of  a  patient  vdxh.  a  strangulated  hernia,  anxious  to  get  his  bowels  to  act. 
Further,  and  in  intestinal  olistruction  generally,  the  bubbling  away  of 
an  enema  may  simulate  the  passage  of  flatus.  In  those  rare  cases 
where,  other  evidence  of  strangulation  being  present,  the  bowels  con- 
tinue to  act  at  intervals,  it  is  probable  that  the  constriction  of  the  bowel 
is  not  complete,  and  leaves  a  channel  along  the  mesenteric  border.  In 
such  cases  which  have  been  left  long,  owing  to  the  absence  of  constipation 
and  perhaps  the  slightness  of  the  vomiting,  the  surgeon  must  examine 
the  bowel  very  carefully  before  he  returns  it.  Constriction,  though  only 
partial,  may  have  here  caused,  from  its  long  duration,  thinning  or 
ulceration  of  the  intestine  at  one  spot,  and  frecal  extravasation  may 
take  place  as  soon  as  the  bowel  is  returned.  If  there  is  any  reason 
for  doubt  in  these  cases  the  stricture  should  be  thoroughl}^  divided  and 
the  bowel  left  in  situ. 

iii.  Vomiting.* — Especially   if  («)  this  is   changing  from  the  early 


*  Sir  J.  Paget  (lop.  svpra  cit.,  p.  112)  says:  "If  I  were  asked  which  of  the  signs  of 
strangulation  I  would  most  rely  on  as  commanding  the  operation,  I  should  certainty 
say  the  vomiting."  Later  on  (p.  114)  he  urges  that  the  practitioner  should  not  wait  for 
any  characteristic  mode  of  vomiting,  nor  be  misled  by  the  absence  of  any  particular 


STIJAXGULATED  FEMORAL  HERNIA.  35 

rejection  of  stomach  contents  or  bile  to  ftecnlent  fluid ;  {!>)  even  if  it  is 
repeated  only  at  long  intervals,  and  all  other  signs  are  absent  or  little 
marked;  (c)  it  must  be  remembered  that  vomiting  may  be  stopped  by 
drugs,  strangulation  persisting,  or  the  intestines  may  be  empty. 

iv.  Tympanites  and  other  evidence  of  peritonitis. 

These  will  not.  of  course,  debar  the  surgeon  from  operating,  but  the}- 
will  lead  him  to  warn  the  friends  that  relief  will  probably  come  too  late. 


STRANGULATED    FEMORAL    HERNIA    (Fig.  7). 

Operation.* — The  parts  being  shaved  and  thoroughly  cleansed,  a  little 
iodoform  rubbed  in  around  the  genitals,  the  limbs  being  kept  warm  with 
blankets  and  a  hot  bottle  or  two  if  the  patient's 
vitality  is  low,  and  the  knee  flexed  slightly  over  P^^. 

a  pillow,  an  incision  two  and  a  half  to  tlu-ee  inches 
long  is  made  vertically  on  the  inner  side  of  the 
swelling.  Some  small  branches  of  the  superficial 
external  pudic  occasionally  require  torsion  or 
ligature.  The  cribriform  fascia  and  the  fascia 
propria  (femoral  sheath  and  septum  cruralcj 
are  next  divided  in  the  same  vertical  line, 
with  or  without  a  director,!  according  to  their 
thickness  and  the  experience  of  the  operator,  all 
the  incisions  made  going  quite  up  to  and  above 
the  top  of  the  swelling,  so  as  to  lie  over  the  seat 
of  strangulation,  usually  Gimbernat's  ligament. 

In  the  operation  without  opening  the  sac,^  the  site  of  stricture  must 
next  be  found.  The  varieties  here  are  best  given  in  Sir  James  Paget's 
words  (he.  supra  cit.,  p.  132):  "  In  some  instances,  as  you  trace  up  the 
neck  of  the  sac,  3'ou  find  it  tightly  banded  across  by  a  layer  of  fibrous 
tissue  called  Hey's  ligament — a  layer  traceable  as  a  falciform  edge  of 
the  fascia  lata,  where  that  fascia,  bounding  the  upper  part  of  the 
saphenous  opening,  is  connected  with  the  crural  arch,  and  is  tlience 
continued  to  Gimbernat's  ligament.     Sometimes  a  fair  division  of  this 

fluid,  nor  even  by  the  absence  of  all  vomiting,  nor  under-estimating  the  importance  of 
occasional  vomiting  as  a  signal  for  operation. 

*  While  general  auc^sthesia  will  be  preferred  in  most  cases  from  the  more  certain  loss 
of  sensibility  and'  the  relaxation  of  the  parts,  a  case  related  by  Dr.  Mason  iBrit.  Med. 
Journ.,  vol.  i.  p.  834)  shows  how  valuable  cocaine  may  be  as  a  local  aniesthetic.  A 
woman  who  had  suffered  from  heart  disease  for  many  years  required  operation  for  a 
strangulated  femoral  hernia.  Three  four-minim  injections  of  a  4  per  cent,  solution  of 
cocaine  were  given,  the  first  under  the  skin  over  the  centre  of  the  tumour,  the  second 
above  and  the  third  below  the  tumour,  as  deeply  towards  the  femoral  ring  as  was  thought 
safe.  It  was  only  during  actual  division  of  the  sac  and  the  insertion  of  the  sutures  that 
any  pain  was  complained  of.     The  wound  healed  by  first  intention. 

t  The  operator  can  also  manage  very  well  with  scissors,  keen-edged  but  blunt-pointed, 
first  nicking  each  layer,  and  then  separating  it  from  the  next  with  the  closed  points. 

+  Cases  best  suited  for  this  plan  are  those  where  the  strangulation  has  been  short ; 
its  symptoms  not  very  severe—*?.^.,  the  vomiting  only  bilious  ;  where  the  hernia  is  small 
in  size  and  without  mi.xed  contents  ;  where  the  patient  is  in  good  condition,  and  any 
previous  taxis  has  been  gentle  and  brief. 


36  OPERATIOXS  OX  THE  ABDOMEX. 

layer  of  fibres  up  to  the  edge  of  the  crural  arch  is  sufficient  to  render  the 

hernia  reducible But  in  more  cases  this  is  not  sufficient,  and  you 

may  feel  the  stricture  formed  by  bands  of  fibres  which  encircle  the  neck 
of  the  sac,  and  which  must  be  divided,  band  by  band  and  layer  bj^  layei', 
till  none  can  be  felt.  These  fibres  are  part  of  the  deep  crural  arch. 
Ver}^  rareh*.  however,  even  the  division  of  these  is  not  sufficient,  for  the 
stricture  is  formed  by  thickening  of  the  mouth  of  the  sac  itself.  This 
condition,  which  is  a  common  cause  of  stricture  in  inguinal  hernia,  is 
very  rare  in  femoral ;  but  it  certainly  does  occur,  and  in  any  case  well 
suited  for  the  operation,  without  opening  the  sac,  you  may  try  to  thin 
the  mouth  of  the  sac  withoiTt  opening  it,  and  thus  to  make  it  extensible 
enough  for  the  return  of  its  contents.  You  ma}^  try  this,  but  the  chances 
of  success  are  small.  You  are  much  more  likely  to  cut  into  the  sac  at 
some  thin  place,  and  when  j^ou  have  done  this  you  had  better  enlarge 
the  opening  and  divide  tlie  stricture  from  within."* 

Operation  by  Opening  the  Sac. — This,  with  very  few  exceptions,  is 
the  method  to  be  employed.  For  many  reasons  it  is  better  and  more 
satisfactory,  and  of  these  the  two  following,  apart  from  others,  will 
justify  its  performance  in  the  majority  of  cases:  i.  The  importance  of 
inspecting  the  bowel;  2.  It  renders  an  attempt  at  radical  cure 
possible. 

In  this  and  in  the  former  case  much  difficulty  is  occasionally  met 
with  in  deciding  as  to  whether  the  sac  is  reached  or  no.  The  causes 
of  difficulty  here  are  mainl}- — (i)  An  altered  condition  of  the  soft 
jiarts  from  the  pressure  of  a  truss,  or  from  long  strangulation ; 
(2)  from  meeting  with  fluid  outside  the  sac ;  (3)  from  the  extreme 
thinness  of  the  patient,  which  leads  to  the  sac  being  reached  iin- 
expectedly ;  (4)  from  the  opposite  condition,  much  fat  being  met  with 
in  several  of  the  deep  layers,  making  it  uncertain  which  is  the  extra- 
peritonasal  laj^er,  the  fat  in  these  cases  being  often  soft,  and  readily 
breaking  down  under  examination ;  (5)  an  apparently  puzzling  number 
of  la^'ers — this  condition  is  usuallj^  due  to  "hair-splitting"  over- 
carefulness  on  the  part  of  the  operator,  at  other  times  it  is  brought 
about  b}^  a  much  thickened  fascia  propria  separated  into  imperfect 
layers  by  its  softened  condition  or  inflammatorj^  matting ;  (6)  by  the 
absence  of  a  sac.f 

Aids  in  Recognisijig  the  Sac  in  Cases  of  Difficulty. — Several  of  those 
ordinarilj'-  given  (Erichsen,  loc.  supra  cit.) — e.g.,  "  its  rounded  and  tense 
appearance,  its  filamentous  character,  and  the  arborescent  appearance  of 
vessels  on  its  surface " — are,  I  think,  quite  fallacious.  So,  too,  with 
regard  to  the  escape  of  fluid  from  the  sac,  for  this  is  often  dry  in  femoral 
hernise,  and  occasionally  fluid  is  met  with  before  the  sac  is  reached.  A 
smooth  lining  characteristic  of  its  inner  surface  is  more  reliable,  but  the 


*  In  trying  to  divide  points  of  stricture  outside  the  sac,  attention  should  be  paid  to 
the  following: — (i)  First  reaching  the  sac  itself,  if  possible,  by  a  careful  division  of  all 
the  overlying  structures  in  the  vertical  incision  carried  well  upwards ;  (2)  carefully 
drawing  down  the  sac,  so  as  to  expose  any  fibres  constricting  its  neck ;  (3)  gently 
insinuating  the  point  of  the  director  under  any  bands  met  with. 

f  A  sac  is  said  to  be  absent  in  some  cases  of  hernia  of  the  ciecum,  and  where  the 
patient  has  been  operated  on  before.  This,  however,  was  not  the  case  in  three  hernise 
containing  the  caecum,  and  in  two  which  had  been  operated  011  before,  that  have  come 
under  my  care. 


STRANGULATED  FEMORAL  HERNL\.  37 

inner  surface  of  the  fascia  propria  is  sometimes  remarkably  smooth. 
Two  points  remain  wliich  will  help  to  solve  the  doubt — (a)  To  draw 
gently  down  the  doubtful  structure,  whether  sac  or  bowel,  and  to  examine 
whether  it  is  continuous  above  and  below  with  the  structm-es  of  the 
abdomen  and  thig-h,  like  the  other  covering's  of  the  hernia,  or  whether  it 
has  a  distinct  neck  to  be  traced  into  the  abdominal  cavity ;  (Ji)  To  see  if 
the  point  of  a  Key's  director  can  be  insinuated  along  this  last  doubtful 
layer  into,  and  moved  within,  the  peritonaeal  cavit}^  or  no.  In  a  very 
few  cases  the  surgeon,  if  still  in  doubt,  incises  carefully  the  suspected 
layer,  and  tries  if  he  can  pass  in  a  probe  and  move  it  from  side  to  side ; 
if  this  can  be  done,  he  is  still  outside  the  bowel,  not  between  the 
peritonaeal  and  muscular  coats  of  intestine. 

The  sac  being  carefully  nicked  with  the  scalpel-blade  held  horizontally 
at  a  spot  where  it  can  best  be  pinched  up  with  dissecting-forceps — a 
matter  of  much  difficulty  at  times,  owing  to  its  tenseness — is  slit  up  on  a 
director,  and  its  contents  examined.  If  omentum  first  present  itself, 
this  is  drawn  to  one  side  and  unravelled,  and  intestine  sought  for.  This 
usually  takes  the  form  of  a  small,  very  tense  knuckle,  of  varying  colour 
and  condition.  If  it  will  facilitate  the  manipulations  needful  for 
reduction,  the  omentum  may  be  first  dealt  with,  (i)  If  this  be  volumin- 
ous and  altered  in  structure,  it  should  be  tied,*  bit  by  bit,  with  reliable 
chromic  gut  or  silk,  and  then  cut  away,  the  scissors  being  applied  so 
close  to  the  ligatures  as  to  leave  holding-room,  but  no  excess  to  mortify 
or  slough.  After  the  return  of  the  intestine,  the  stump  is  also  replaced 
within  the  abdomen.  (2)  If  the  omentum  be  small  in  amount  and 
recently  descended,  it  may  be  merely  returned.  (3)  In  a  few  rare  cases 
when  the  omentum  is  intimately  adherent  to  the  sac,  and  the  patient's 
condition  does  not  admit  of  delay,  the  otnentvim  must  be  left  in  sihi. 
As,  however,  this  course  very  much  interferes  with  the  satisfactory 
wearing  of  a  truss,  and  as  it  is  likely  to  lead  to  a  fresh  descent  of  bowel, 
it  should  never  be  followed  if  it  can  be  avoided. 

Reduction  of  the  Intestine. — As  soon  as  this  is  exposed,  the  surgeon 
examines  with  the  little  finger-nail,  or  a  Key's  director,  the  tightness  of 
Gimbernat's  ligament.  In  a  few  cases  reduction  may  be  at  once  effected 
by  gentle  pressure  backwards  on  the  bowel  with  the  tip  of  the  little 
finger.  But  in  the  large  majority  the  above  site  of  stricture  will  need 
division — a  point  requiring  much  carefulness  for  fear  of  injuring  the 
intestine  or  important  surrounding  structures.  If  the  degree  of  tightness 
of  the  parts  admit  of  it,  there  is  no  director  so  safe  and  satisfactory 
as  the  index  or  little  finger  of  the  left  hand  passed  up  to  the  stricture, 
and  the  nail-tip  insinuated  beneath  this,  the  hernia-knife  being  introduced 
along  the  pulp  of  the  finger  (Fig.  8).  But  there  is  rarely  room  for 
this,  and  a  Key's  directorf  must  usually  take  the  place  of  the  finger. 


*  For  security's  sake  the  ligatures  should  be  made  to  interlock.  If  haemorrhage  occur 
from  the  omentum  after  it  has  been  replaced,  the  surgeon  must  remember  tliat  returned 
omentum  generally  escapes  far  from  the  wound.  It  will  thus  be  usually  needful  to 
extend  the  wound  upwards  along  the  linea  semilunaris. 

t  This  director  is  broad,  so  as  to  prevent  any  intestine  curling  over  and  reaching  the 
knife  ;  blunt-pointed,  so  as  not  to  damage  the  contents  of  the  peritonaeal  cavity  ;  finally, 
its  groove  does  not  run  quite  up;  to  the  end,  so  that  the  knife-point  shall  be  stopped 
before  it  conies  in  contact  with  the  important  parts. 


38 


OPERATIONS  OX  THE  ABDOMEN. 


Fig.  8.t 


The  tip  of  this  instrument  being  insinuated  into  the  periton^eal  cavity 
just  undei'  Gimbernat's  ligament,  the  hernia-knife*  is  introduced  obHquely 
or  flat-wise  upon  it,  its  end  slipped  under  and  beyond  the  ligament,  its 
edge  turned  towards  the  constricting  fibres,  and  a  few  of  these  gently 

cut  through  in  an  upward 
and  inward  direction.  In 
doing  this  it  is  well  for  the 
surgeon  to  draw  doA\'n  the 
edges  of  the  cut  sac  close 
to  its  neck,  and  to  ask  an 
assistant  to  hold  these,  thus 
facilitating  the  passage  of 
the  director  and  the  knife 
by  preventing  the  sac  fall- 
ing into  folds  before  them. 
Occasionally,  also,  a  knuc- 
kle of  intestine  persistently 
This  is  best  met  by  patience,  by 


(Fergussou. 

coils  over  the  edge  of  the  director. 


drawing  it  out  of  the  wa}'  b}'  the  carbolised  finger-tip  of  an  assistant,  or 
by  pressing  it  down  with  the  handle  of  a  pair  of  dissecting-forceps. 

The  direction  and  the  extent  to  M'hich  the  stricture  must  be  cut  are 
matters  of  much  importance.  The  upward  and  inward  line  is  the  only 
l^ath  of  safety.  Directly  outwards  lies  the  femoral  vein  ;  b}^  cutting 
upwards,  the  spermatic  cord,  and,  if  upwards  and  outwards,  the  epi- 
gastric artery,  would  be  endangered ;  behind  are  the  peritonasum  and 
pubes.  The  incision  upwards  and  inwards  must  be  of  the  nature  of  a 
nick  ;  otherwise,  owing  to  the  imperfect  healing  of  the  fibrous  structure, 
the  ring  will  be  left  large  and  gaping,  thus  facilitating  the  re-descent  of 
the  hernia,  producing  much  difticulty  in  fitting  ti'usses,  and  causing 
certain  discomfort  and  probable  peril  to  the  })atient,  especially  if  she 
belong  to  the  poorer,  hospital  class. 

Gimbernat's  ligament  having  been  carefully  and  sufficient!}^  nicked, 
the  bowel  is  replaced  either  b}^  gentle  squeezing  between  the  finger 
and  thumb,  so  as  to  empty  it  of  its  contents,  or  with  the  pressure  of 
the  little  finger ;  the  sac  being  now  kept  stretched  with  forceps  so 
that  no  folds  interfere  with  the  return  of  the  bowel.  If  pressure  on 
one  part  of  the  intestine  fail,  it  must  be  tried  at  another  point. 
After  the  reduction  of  the  intestine  the  tip  of  the  little  finger  should 
be  introduced  through  the  crural  canal  into  the  peritonseal  cavity  to 
ascertain  that  the  gut  is  absolutely  safe  ;  a  little  sterilised  iodoform  is 
then  dusted  on  to  the  stumps  of  omentum,  and  these  too  returned,  if 
this  has  not  been  done. 

If  the  patient's  condition  and  age  admit  of  it,  and  if  the  adhesions 
are  not  too  firm,  the  sac  should  next  be  taken  away  by  carefully 
separating  it  with  the  finger  or  a  director  from  its  attachments.  It 
should  then  be  pulled  well  forwards,  an  aseptic  finger  introduced  up 


*  A  curved  one  will  be  fouud  most  useful.  The  cutting  blade  is  usually  too  broad 
and  the  tip  too  massive.  On  the  other  hand,  a  worn-down  blade  has  been  known  to 
break  while  dividing  a  tense  Gimbernat's  ligament.  The  intestine  may  thus  be 
■wounded,  or  the  fragment  of  the  knife  escape  into  the  peritonreal  cavitj'. 

t  The  cutting  blade  of  the  knife  shown  here  is  needlessly  long  and  unguarded. 


STRAXGULATEU  FEMORAL   HERNIA.  39 

to  its  neck,  this  part  next  ligatured  with  stout  silk  as  high  up  as 
possible,  the  finger  then  withdrawn,  and  the  sac  cut  away  half  an  inch 
below  the  ligature.  If  the  surgeon  is  at  all  doubtful  about  the  safe 
ligature  of  an)-  stump  of  omentum,  he  should  keep  this  down  and 
transfix  it  and  the  neck  of  the  sac  with  a  double  silk  ligature,  the 
ends  of  which  are  afterwards  cut  short.  Sufficient  drainage  is  now 
provided  by  a  small  tvdje  or  a  bundle  of  horsehair,  and  the  superficial 
wound  closed.  The  dressings  must  be  applied  with  sufficient  care  to 
keep  the  wound  secure  from  obviously  close  sources  of  contamination. 
It  is  well  to  place  a  separate  pad  of  carbolised  tow  or  salicylic  wool 
over  the  anus  and  genitals,  and  to  draw  the  water  off  before  the  patient 
leaves  the  table.  The  thigh  should  not  be  kejot  too  much  Hexed, 
otherwise  the  escape  of  discharge  from  the  drainage-tube  will  be 
interfered  with. 

The  account  of  an  ordinary  operation  having  been  given,  it  remains 
to  consider  certain  complications.     These  are  chiefly  : 

1.  Adhesions  of  Bo\\el  to  the  Sac  or  Omentum. — The  treatment  of 
this  uncommon  com])lication  must  vary  with  (a)  the  character  and 
position  of  the  adhesions.  (/3)  the  condition  of  the  intestines,  and 
{7)  the  state  of  the  patient.  Owing  to  the  difficulty  of  fitting  on  a  truss 
if  an}*  of  the  hernia  is  left  unreduced,  every  attempt  shoiild  be  made  to 
free  the  contents  by  separating  the  adhesions  with  the  point  of  a  steel 
director,  the  finger-nail,  or  a  blunt-pointed  bistoury.  When  near  the 
neck  they  must  always  be  divided,  sufficiently  nicked,  or  stretched. 
No  intestine  and  omentum  still  adherent  to  each  other  should  ever  be 
returned.  A  few  cases  remain  in  which  adhesions  should  be  left 
alone.  When  gangrene  is  threatening,  but  the  operator  is  too  short- 
handed  to  face  resection  of  the  affected  intestine,  the  presence  of  adhe- 
sions, especially  about  the  neck  of  the  sac,  is  the  chief  safeguard  against 
extravasation  into  the  peritona^al  cavity.  In  some  cases  of  large  hernia, 
if  the  patient  be  much  collapsed,  so  long  as  any  recentl}^  descended 
loop  is  returned,  any  long-adherent  intestine  may  be  left.  And  in 
other  cases  of  collapse  from  delay  of  the  operation,  where  there  is  much 
difficulty  in  returning  a  loop  of  intestine,  especially  if  this  be  not  in 
good  condition,  it  may  be  left,  after  the  stricture  has  been  sufficiently 
divided. 

It  occasionally  happens  in  these  cases  of  deeply  congested  bowel, 
especially  in  inguinal  hernia,  that  after  an  otherwise  successful  herni- 
otomy the  patient  passes  profuse  and  blood}^  stools.  This  condition 
may  prove  fatal.  In  one  or  two  cases  of  this  kind  which  have  come 
under  my  notice  the  operator  was,  most  unfairly,  blamed  for  having 
incised  the  bowel. 

Mr.  Kough  (^Liuiret,  Oct.  11,  18S4)  records  a  case  iu  which  a  patient  died  in  collapse 
two  hours  after  the  reduction  of  a  very  large  scrotal  hernia.  The  pelvic  cavity  was  full 
of  blood-stained  serum  ;  ten  feet  of  intestine  were  found  dark  purple  in  colour,  but 
uninjured.     On  laying  the  gut  open  about  a  pint  and  a  half  of  blood  escaped. 

2.  Tightly  Constricted  or  (langrenous  Intestine. — In  spite  of  all  that 
has  been  taught  about  the  importance  of  early  operations,  cases  do  still 
occur  in  which  returning  the  bowel  is  doubtful  or  out  of  the  question. 
In  most  cases  of  doubt,  as  long  as  the  stricture  is  sufficiently  divided 
and  the  intestine  placed  only  just  within  the  crural  ring  (the  wound 


40  OPERATIONS  OX  THE  ABDOMEN. 

being  left  open  and  the  sac  not  ligatured),  the  interior  of  the  abdomen 
is  the  best  place  for  the  intestine.  And  this  is  true  of  congested 
intestine,  however  deeply  loaded  with  blood  onl}^,  as  long  as  there  is 
some  shade  of  red  present.  But  on  these  points  nothing  will  surpass 
the  advice  of  Sir  J.  Paget  (he.  supra  cit.,  p.  138):  "You  are  to  judge 
chiefly  from  the  colour  and  the  tenacity.  Use  your  eyes  and  your 
fingers ;  sometimes  your  nose ;  very  seldom  your  ears,  for  what  you 
may  be  told  about  time  of  strangulation,  sensations,  and  the  rest  is 
as  likely  to  mislead  you  as  to  guide  aright.  As  to  colour  ....  I  am 
disposed  to  say  that  you  may  return  intestine  of  any  colour  short  of 
black,  if  its  texture  be  good;  if  it  feel  tense,  elastic,  well  filled  out, 
and  resilient,  not  collapsed  or  sticky ;  and  the  more  the  surface  of  the 
intestine  shines  and  glistens,  the  more  sure  you  may  be  of  this  rule. 
When  a  piece  of  intestine  is  thoroughly  black,  I  believe  you  had  better 
not  return  it,  unless  you  can  be  sure  that  the  blackness  is  wholly  from 
extravasated  blood.  It  may  not  yet  be  dead,  but  it  is  not  likely  to 
recover ;  and,  even  if  it  should  not  die  after  being  returned,  there  will 
be  the  great  risk  of  its  remaining  unfit  to  propel  its  contents,  and 
helping  to  bring  on  death  by  what  appears  very  frequent^ distension 
and  paralysis  of  the  canal  above  it.  But,  indeed,  utter  blackness  of 
strangulated  intestine  commonly  tells  of  gangrene  already  ;  and  of  this 
you  may  be  sure  if  the  black  textures  are  lustreless,  soft,  flaccid  or 
viscid,  sticking  to  the  fingers,  or  looking  villous.  Intestine  in  this 
state  should  never  be  returned.  Colours  about  which  there  can  be  as 
little  doubt,  for  signs  of  gangrene,  are  wdiite,  grey,  and  green,  all  dull, 
lustreless,  in  blotches  or  complete  over  the  wdiole  protruded  intestine. 
....  Then  as  to  the  texture  of  the  intestine :  it  should  be,  for  safety 
of  return,  thin-walled,  firm,  tense,  and  elastic,  preserving  its  cylindrical 
form,  smooth,  slippery,  and  glossy.  The  further  the  intestine  deviates 
from  these  characters,  the  more  it  loses  its  gloss  and  looks  villous,  the 
more  it  feels  sticky  and  is  collapsed  and  out  of  the  cylinder  form,  the 
softer  and  more  yielding,  the  more  pulpy,  or  like  wet  leather  or  soaked 
paper,  the  less  it  is  fit  for  return.  And  when  these  characters  are 
combined  with  such  bad  colours  as  I  have  described,  the  intestine  had 
better  be  laid  open,  that  its  contents  may  escape  externallv  and  do  no 
harm." 

In  other  long-standing  cases  of  femoral  hernia  the  chief  stress  of  the 
constriction  is  shown,  not  on  a  dying  Ioojd  of  intestine,  but  in  ulcera- 
tion, partial  or  nearly  ring-like,  at  the  neck  of  the  sac,  under  the  sharp 
edge  of  Gimbernat's  ligament.  Where  this  condition,  owing  to  the 
duration  of  the  case,  is  suspected,  the  intestine  shoiild  be  very  gently 
drawn  down,  and,  if  ulceration  be  found,  laid  oi^en.  If  the  mischief  be 
localised,  and  the  adjacent  intestine  fairly  health}^  and  not  fixed,  it  will 
be  well  to  stitch  it  to  adjacent  parts  to  prevent  it  slipping  up  into  the 
peritongeal  cavity. 

The  treatment  of  gangrenous  intestine  in  a  hernia  is  fully  dealt  with, 
later  on,  under  the  heading  of  Resection  of  the  Intestine.  I  will  only 
say  here,  that  wherever  possible,  i.e.,  in  cases  where  the  condition  of 
the  patient,  and  the  experience,  and  help  ready  to  the  surgeon's  hand, 
admit  of  his  taking  this  step,  the  gangrenous  intestine  should  always 
be  resected.  In  a  few  cases  where  the  above  conditions  are  absent,  the 
surgeon  must  rest  content  with  opening  the  intestine  and  leaving  it 


STRAXGULATED  FEMORAL  TTERNIA.  4I 

in  situ.  The  quickest  way  will  be  to  draw  the  whole  loop  that  is 
damaged  outside  the  peritonaeal  sac,  and  keep  it  in  place  by  a 
sterilised  bougie  or  glass  rod  of  appropriate  size,  as  in  inguinal 
colotonw  (q.  v.). 

It  has  been  much  disputed  whether,  in  these  cases.  A\hen  the  intes- 
tine is  unfit  to  be  returned,  it  is  safe  or  needful  to  divide  the  stricture 
in  addition  to  laying  open  the  intestine.  On  the  one  hand,  M.  Dupuy- 
tren,  Sir  A.  Cooper,  Mr.  Kej',  and  Sir  J.  E.  Erichsen  have  advocated 
this  step  being  taken ;  on  the  other,  Mr.  Travers  and  Sir  W.  Lawrence 
were  against  it.  The  following  words  of  a  very  brilliant  writer*  will 
probably  convince  most  that  this  step  is  not  only  injurious  but  un- 
needed  :  "  The  only  result  of  this  is  that  the  protecting  barrier,  which 
divides  the  still  aseptic  peritongeal  cavity  from  the  putrid  sac,  is 
broken  down,  and  putridity  spreads  upwards  into  the  abdomen  and 
kills  the  patient  by  rapid  septicjemic  poisoning.  Why  break  down 
this  valuable  wall  ?  If  it  is  argued  that,  iTuless  the  stricture  is  divided, 
the  contents  of  the  bowel  cannot  escape,  then  the  reply  is  that  expe- 
rience proves  this  to  be  utterly  untrue.  In  a  very  short  time  both 
tiatus  and  fasces  find  their  way  out.  As  everyone  knows,  the  nipping 
of  the  gut  is  not  produced  by  a  sudden  narrowing  of  the  hernial  ajier- 

ture,  but  by  a  swelling  of  the  loop  of  gut ^Vhen  the  gut  is  slit 

up,  its  contents  are  set  free,  and  its  inflammatory  juices  escape,  ^vith 
the  result  that  its  swelling  goes  down,  and  room  enough  is  soon  per- 
mitted for  wind  and  ffeces  to  pass,  more  particularly  as  the  faeces  are 
invariably  quite  liquid."" 

3.  Wound  of  Intestine. — This  may  be  due  to  (a)  carelessly  incising 
thin,  soft  parts ;  (/>)  great  difficulty  in  making  out  the  sac  and  the 
intestine  in  a  fat  patient,  with  the  parts  matted,  especially  if  the  light 
is  bad ;  (c)  to  the  intestine  being  allowed  to  curl  over  the  edge  of  the 
director  while  the  stricture  is  being  divided,  or  to  this  being  cut  with 
careless  freedom,  or,  lastly,  to  a  loop  Ij^ing  out  of  sight  just  above  the 
constriction,  and  to  the  hernia-knife  coming  in  contact  with  this.  Any 
bubbling  of  flatus  or  escape  of  fseces  must  lead  to  a  careful  search  for 
the  wound.  The  oi>eration  wound  being  freely  enlarged,  the  wound 
in  the  intestine  found,  temporarily  closed  with  a  Spencer  Wells's 
forceps,  and  drawn  quite  out  of  the  abdomen,  the  intestines  around 
are  carefully  cleansed  and  packed  out  of  the  way,  and  protected  with 
tampons  of  iodoform  gauze  or  flat  sponges.  When  the  wound  in  the 
intestine  is  small,  it  may  usually  be  tied  iip  around  a  pair  of  dissecting- 
forceps  Avith  carbolised  silk,  the  ligature  not  being  tied  too  tightly,  and 
the  ends  cut  short.  If  the  opening  be  larger,  it  should  be  closed  by 
Lembert's  suture  (see  Suture  of  the  Intestine).  Whichever  method  is 
used,  the  injured  part  should  be  replaced  just  within  the  peritonjeal 
cavity,  and  in  a  severe  case  the  sac  should  not  be  taken  away  or  the 
wound  closed.  The  patient  should  be  kept  under  the  influence  of  opium, 
and  liquids  restricted. 

4.  Wound  of  Obturator  Artery. — The  position  of  this  vessel  when  it 
rises  by  a  common  trunk  with  the  deep  epigastric  instead  of  from  the 
internal  iliac,  which  occurs  in  two  out  of  ever}''  seven  (Gray),  may  bear 


*  Sir  W.  Banks,  Clinical  2^'uL'S  on  Two  I'mrn'  Surtjical  Work  in  the  Livcrj)ool  Royal 
Infirmary,  p.  96. 


42  OPERATIONS  OX  THE  .IBDOMEX. 

a  very  inipoitant  relation  to  the  crural  ring.  In  most  cases  "vvlien  thus 
arising  abnormally,  the  artery  descends  to  the  obturator  foramen  close 
to  the  external  iliac  vein,  and  therefore  on  the  outer  side  of  the  crural 
ring  and  out  of  harm's  way.  In  a  small  minority  of  cases  the  artery 
in  its  passage  do^vn^^-ards  curves  along  the  margin  of  Gimbernat's  liga- 
ment, and  may  now  be  easily  wounded. 

The  treatment  is  mainly  preventive — i.e.,  by  making  the  smallest 
possible  nick  that  will  be  sufficient  into  any  point  of  stricture,  such  as 
Gimbernat's  ligament,  a  point  the  importance  of  which  has  alreadj'' 
been  alluded  to  (p.  38),  and  by  using  a  hernia-knife  that  is  not  over- 
sharp.  If  the  arter}^  has  probabl}-  been  wounded,  the  following  points 
are  of  interest: — (i)  The  hasmorrhage  may  not  at  once  follow  the 
wound.  It  may  not  make  its  appearance  till  the  bowel  is  all  reduced, 
or  even  until  a  quarter  of  an  hour  after  the  wound  has  been  stitched 
up.  In  one  case,  that  of  Dupuytren,  no  haemorrhage  occurred,  and  the 
division  of  the  artery  was  discovered  for  the  first  time  at  the  necropsy 
three  weeks  after  the  operation.  (2)  It  may  occur  when  the  sac  has 
not  been  opened.  (3)  As  is  shown  by  Dupuytren's  case,  it  is  not  neces- 
sarily a  fatal  accident.  (4)  Very  various  means  have  served  to  arrest 
the  heBmorrhage.  (a)  Pressure,  as  in  the  cases  of  Sir  W.  Lawrence, 
Mr.  Hey,  and  Mr.  Barker.*  This  means  was  successful  in  two  out  of 
the  three  cases  in  Avhich  it  has  been  employed.  It  should  only  be 
resorted  to  when  the  patient's  condition  does  not  admit  of  the  wound 
being  enlarged,  and  the  bleeding  points  found  and  dealt  with  by  ligature 
or  forci-pressure.  When  pressure  has  to  be  trusted  to,  it  should  be  effi- 
ciently employed  b}'  means  of  tampons  of  iodoform  gauze  wrung  out  of 
carbolic  acid  lotion  (i  in  20)  and  secured  on  silk.  (^8)  Ligature  of  the 
vessel,  usually  the  proximal  end.  Of  five  cases  given  by  Mr.  Barker, 
this  was  successful  in  four ;  it  is  only  stated  in  one  that  the  distal  end 
Avas  also  secured.  The  ligature  had  been  applied  in  some  cases  Iw  con- 
tinuing the  M'ound  upwards  ;  in  others  by  making  an  incision  parallel 
with  Poupart's  ligament,  as  if  for  tying  the  external  iliac.  This  step 
should  always  be  taken  when  the  patient's  condition  is  satisfactorj-.f 
In  two  of  Sir  W.  Lawrence's  cases  the  fainting  of  the  patient  appears  to 
have  decided  the  cessation  of  haemorrhage.  Both  of  these  recovered. 
(7)  In  the  event  of  ligature  being  really  impossible,  it  might  be  worth 
while,  before  taking  other  steps,  to  try  the  application  of  a  pair  of 
Spencer  Wells's  forceps.  These  should  be  left  in  situ  for  three  or  four 
days,  and  would  favour  drainage. 

5.  Hernise  with  Unusual  Contents. — These  may  be  (a)  Fat  hernige. 
Both  in  the  inguinal  and  femoral  regions,  but  especially  in  the  latter, 
the  extra-peritona?al  tissue  near  the  rings  may  become  increasingly 
fatty.  Gradually  projecting  towards  the  surface,  it  drags  down  the 
peritonaeum  to  which  it  is  loosely  connected.     I  have  operated  on  one 

*  Clin.  Soc.  Trans.,  vol.  xi.  p.  180.  This  paper  ^vill  well  repay  perusal.  Most  of  the 
above  informatJon  is  taken  from  it. 

t  Mr.  Hulke  (^Lancet,  1885,  vol.  i.  p.  746).  by  freely  opening  up  the  wound  and  using 
large  retractors,  found  a  comparatively  large  atheromatous  artery  spouting  freely. 
From  its  position  this  was  a  large  communicating  artery  between  the  deep  epigastric 
and  obturator,  lying  just  behind  Gimbernat's  ligament.  Both  ends  were  secured  with 
very  great  difficulty.     The  patient  did  well. 


STRANGULATED  FEMORAL   HERXIA.  43 

such  case  in  a  girl,  aged  19,  in  whom  the  fitting  of  a  truss  was  un- 
satisfactoiy.  Here  I  expected  to  find  an  omental  hernia.  Into  the 
pouch  so  formed  intestine  or  omentum  maj'  present.  In  other  cases,  if 
the  extra-peritona?al  fat  thus  protruded  become  absorbed,  the  hollow 
thus  left  may  produce  a  space  for  the  peritonasum  to  project  into. 
(IS)  Hernia  of  the  ovary.  This  is  much  more  commonly  met  with  in 
inguinal  hernias.  The  chief  points  in  the  diagnosis  of  these  difiicult 
oases  are  the  characteristic  oval  shape  and  size  of  the  swelling;  the 
peculiar  sickening  pain  when  the  swelling  is  pressed  upon;  the  swelling 
being  larger  and  the  tenderness  greater  during  menstruation  ;  the  swelling 
maj'  sometimes  be  made  to  move  when  the  uterus  is  displaced  laterally 
with  a  vulsellum,  and  the  ovary  of  that  side  is  not  to  be  made  out  per 
rarjinam.  AVhere  other  treatment  has  failed,  where  the  swelling  is 
irreducible  and  prevents  the  fitting  of  a  truss,  where  the  symptoms  are 
suflSciently  urgent  to  cripple  a  young  life,  the  displaced  ovary  should  be 
removed.  The  operation  should  be  rigidly  aseptic.  Adhesions  are  not 
uncommon.     (7)  Hernia  of  vermiform  appendix. 

I  met  with  a  case  of  this  early  in  1890,  in  a  lady,  aged  43,  a  patient  of  Dr.  Fraser's, 
of  Eomford.  The  femoral  hernia  was  here  irreducible,  dull,  gave  a  feel  of  omentum, 
and  curved  upwards  and  outwards  in  the  usual  way.  As  no  truss  was  satisfactory,  and 
as  the  patient,  the  vrife  of  a  missionaiy,  was  to  be  much  abroad,  a  radical  cure  was 
advised.  The  sac  contained  much  fluid,  but  no  omentum.  In  the  outer  part  of  the 
hernia  lay  a  thick  fleshy  body,  tubular  and  expanded  at  its  end.  Near  Gimbernat's 
ligament  it  was  constricted  and  distinctly  abraded.  After  notching  the  above  ligament, 
this  body,  which  proved  to  be  the  appendix,  was  easily  returned.  The  sac  was  removed. 
The  case  did  excellently. 

In  another  case  I  should  remove  the  appendix  if  there  were  time  for 
making  the  necessary  suturing  secure.  (8)  Hernia  with  more  than 
one  sac.  This  may  be  due  to  the  presence  of  membrane,  inflammatory 
in  origin,  \\hich  has  divided  the  original  sac. 

Causes    of    Herniae    not     doing     well     after     the     Operation.  — 

(1)  Peritonitis,  usually  from  the   operation  being  performed  too   late. 

(2)  Enteritis.  This  may  be  told  by  the  tympanites,  tenderness  and 
vomiting  being  much  less  marked,  and  often  the  presence  of  diarrhoea. 
{3)  Septic  trouble,  erysipelas.  The  eight  following  are  the  causes  of 
intestinal  obstruction  after  operations  for  hernia :  (4)  The  descent 
and  re-strangulation  of  the  bowel.  (5)  So  much  damage  to  the 
intestine  that  it  lies  paralysed  in  the  peritona?al  cavity.*  (6)  Cica- 
tricial stricture  of  the  intestine.  (7)  Fixing  of  the  bowel,  after  its 
reduction,  by  adhesions  to  the  abdominal  wall.t  (8)  Formation  of  a 
band  out  of  the  above  adhesions.  (9)  Fixing  of  the  two  ends  of  a  loop 
of  intestine  by  adhesions.  (10)  Formation  of  an  omental  band  in  the 
neighbourhood  of  one  of  the  hernial  orifices,  a  band  so  formed  causing 
■obstruction  later  (Brit.  Med.  Journ.,  1879.  vol.  ii.  p.  491).  (i  i)  A  very 
rare  condition.  The  sac  may  be  multilocular ;  when  the  intestine  is 
reduced  it  may  be  returned  into  one  of  these  cavities  instead  of  within 
the  abdomen.     Mr.  Bellamy  has  published  such  a  case  (Lancet,  1886, 

*  I  have  recorded  (7inY.  Jlcd.  Journ..  1879,  vol.  ii.  p.  491)  an  instance  of  this  in  which, 
ten  days  after  an  operation  for  intestinal  obstruction  by  bands,  death  took  place  from 
the  intestine  never  having  recovered  itself. 

f  This  and  the  next  three  are  given  by  Mr.  Treves,  Laiwct,  1884,  vol.  i.  p.  1022. 


44  OPERATIONS  ON  THE  ABDOMEN. 

vol.  ii.  p.  433).  A  good  illustration  of  this  is  given  in  Mr.  Holmes's 
Surgery,  p.  698,  Fig.  322 ;  the  patient  here  died  eight  daj^s  after 
an  operation  for  strangulated  hernia. 


STRANGULATED    INGUINAL    HERNIA  (Figs.  9  and  10). 

Operation. — In  considering  this  it  will  not  be  needful  to  go  again 
into  detail,  as  in  the  case  of  Strangulated  Femoral  Hernia ;  the  chief 
points  of  difference  and  those  of  imj^ortance  will  be  considered  carefully. 

The  parts  being  shaved  and  cleansed,  and  the  thigh  a  little  flexed, 
an  incision  four  inches  long  at  first  is  made  in  the  long  axis  of  the 
tumour,  with  its  centre  (in  an  ordinary  scrotal  case*)  over  the  external 
abdominal  ring.  This  incision  may  be  made  either  by  pinching  up  a 
fold  and  cutting  from  within  outwards,  or  by  cutting,  in  the  usual  way, 
from  without  inwards.  The  pressure-forceps  ma}'  be  left  on  the  external 
pudics  (both  superior  and  inferior),  these  vessels  being  finally  closed  by 
the  sutures  which  unite  the  wound.  As  the  layers  are  divided,  the 
knife  being  kept  strictly  in  the  same  line  throughout,  some  arching 
fibres  of  the  inter-columnar  fascia  may  be  seen  above,  but  the  first  layer 
usually  recognised  is  the  cremasteric  fascia,  often  much  thickened. 
After  this  the  transversalis  fascia,  also  much  thickened  and  vascular- 
looking,  is  slit  up,  and  any  extra-peritongeal  fat  overlying  the  greyish- 
blue  sac  looked  for.  The  surgeon  now  sees  if  he  can  find  any  constricting 
fibres  outside  the  sac,  and  slits  them  up  on  a  director.  The  more 
voluminous  the  hernia  the  more  important  it  is  to  avoid  exposure 
and  manipulation  of  its  contents  by  opening  the  sac.f  But  in  the 
majority  of  inguinal  hernise  the  surgeon  must  be  prepared  for  opening 
the  sac.  As  soon  as  this  is  done,  with  the  precautions  already  given 
(p.  37),  the  contents  are  examined,  omentum  got  rid  of  if  this  step 
will  give  more  room,  and  the  site  of  stricture  found  with  the  finger- 
nail or  tip  of  the  director.  It  is  next  divided  with  the  hernia-knife 
manipulated  under  it  in  a  direction  straight  upwards,  so  as  to  lie 
parallel  with  the  deep  epigastric,  whichever  side  of  the  hernia  this 
vessel  occupies.:}:      During  this   stage  the  steps  given  at  p.   38  must 

*  In  a  strangulated  bubonocele  the  centre  of  the  incision  should  lie  over  the  internal 
abdominal  ring,  and  in  the  deeper  part  of  the  incision  the  deep  epigastric  must  be  felt 
for,  and  avoided. 

f  The  site  of  the  stricture  in  inguinal  hernia  varies.  In  both  varieties,  in  old  cases 
of  long  duration,  it  is  usually  situated  in  the  neck  of  the  sac  itself,  owing  to  contrac- 
tion and  thickening  of  this  and  the  extra-peritonajal  tissue.  In  other  cases  of  oblique 
hernia  the  stricture  is  found  in  the  infundibuliform  fascia  at  the  internal  ring,  just 
below  the  edge  of  the  internal  oblique  in  the  canal,  or  at  the  external  ring.  In  a  direct 
hernia  the  constricting  point,  if  not  in  the  sac,  is  probably  caused  by  the  fibres  of  the 
conjoined  tendon.  In  many  cases  the  parts  are  so  approximated  and  altered  that  in 
the  short  time  given  for  an  operation  it  is  not  so  easy  to  tell  exactly  in  what  tissues  lie 
the  strangulation,  as  to  relieve  it.  Finally,  in  many  cases  of  young  subjects  and  acute 
strangulation,  muscular  spasm — e.f/.,  of  the  internal  oblique — must  be  borne  in  mind. 

X  Of  course,  if  the  surgeon  is  certain  that  he  is  dealing  with  an  oblique  hernia,  he 
may  cut  outwards,  and,  in  the  case  of  a  direct  hernia,  inwards,  so  as  to  avoid  the  deep 
epigastric.  In  all  cases  the  cut  should  be  of  the  nature  of  a  nick  dividing  only  those 
fibres  which  actually  constrict,  any  additional  dilatation  being  usually  now  effected  by 
the  tip  of  the  director  or  finger. 


STEAXGULATED  INGUINAL  HERNIA. 


45 


be  taken  to  avoid  any  injury  to  the  intestine.  The  constricting-  point 
being  divided  and  dilated,  the  next  step  is  reduction  of  the  intestine. 
This,  in  bulky  inguinal  hernige,  is  often  a  matter  of  difficulty  and  time. 
The  chief  causes  of  difficulty  here  are — (i)  A  large  amount  of  in- 
testine, one  or  two  coils  of  small  and  some  large  intestine  being  not 
very  uncommon.  (2)  The  distension  of  these  with  flatus,  &c.  (3)  In- 
sufficient division  of  the  stricture ;  or  there  may  be  a  point  of  stricture 
higher  up  than  the  one  divided,  and  overlooked.  (4)  During  attempts 
at  reduction  one  bit  of  intestine  may  get  jammed  across  the  ring 
instead  of  slipjiing  up  along  it,  and  against  this  the  rest  of  the  con- 
tents are  fruitlessly  pressed.  (5)  Folds  of  the  sac  may  in  much  the 
same  wa}^  block  the  opening. 

Aids  in  Difficult  Cases. — First,  that  part  which  lies  nearest  the  ring 
should  be  taken — e.g.,  mesenter}^  before  intestine.  After  each  part  is 
got  up,  pressure  should  be  made  on  it  for  a  few  seconds  before  another 
is  taken  in  hand.  If  the  surgeon  find,  after  a  while,  that  he  is  making 
no  progress  with  one  end  of  a  coil,  he  should  take  in  hand  the  other 

Fig.  q. 


(Fergusson.) 

end,  or  another  coil  altogether  if  more  than  one  be  ])resent.  Much  of 
the  difficulty  met  with  in  the  reduction  of  the  intestine  is  due  to  the 
surgeon  not  first  unravelling  the  coil  or  coils,  not  duly  tracing  up  the 
intestine  to  the  ring  so  as  to  make  out  the  relations  of  the  two,  and,  above 
all,  to  his  not  making  up  his  mind  which  end  of  the  coil  it  is  exactly 
which  he  intends  to  begin  reducing.  During  the  manipulations  the 
thigh  should  be  flexed  and  rotated  a  little  inwards,  and  the  cut  edges  of 
the  sac  drawn  tense  with  forceps,  so  as  to  prevent  any  folding  or  i)ush- 
ing  up  of  this  before  the  intestine.  If  the  intestines  are  much  distended, 
attempts  should  be  made  to  return  some  of  their  contents  first  into  the 
abdominal  cavity.  If,  after  gentle  squeezing  with  the  finger  and  thumb, 
and  careful  pressure  upwards  on  each  successive  bit  of  intestine,  it 
all  appears  to  be  returned,  the  little  finger  must  be  passed  into  the 
abdominal  cavity  to  make  certain  that  no  knuckle  remains  in  the  canal 
or  internal  ring. 

Another  Method. — In  the  case  of  large  scrotal  hernias,  where  opening 
the  sac  in  the  ordinary  way  involves  much  exposure  of  peritona^al  sur- 
faces, I  believe  the  following  to  be  preferable  :    A  small  opening,  just 


46 


OPERATIONS  OX  THE  ABDOMEX. 


large  enough  to  admit  the  left  index  finger  (previously  rendered  aseptic)^ 
is  made  in  the  sac  just  below  the  seat  of  constriction.  This  is  then 
divided  on  the  finger  as  a  director,  from  vithoid  hurards.  The  sac 
should  not  be  again  opened  here,  but  after  all  the  constricting  bands  have 
been  felt  and  perhaps  heard  to  give  way,  the  finger  easily  dilates  the 
communication  with  the  peritongeal  cavity  and  then  reduces  the  contents 
of  the  sac.  I  have  used  this  method  twice,  and  with  excellent  results. 
It  reduces  the  necessary  disturbance  of  peritonseal  surfaces  to  a  minimum. 
Where  from  long  strangulation  or  the  acuteness  of  the  symptoms  it  is 
advisable  to  inspect  the  contents  of  the  sac,  or  where  these  are  adherent, 
the  sac  must  be  more  freely  opened. 

Cases  will  occasionally  be  met  with,  where,  owing  to  the  low  condition 
of  the  patient,  the  large  amount  of  intestine  down,  its  great  distension^ 

Fig.  10. 


(Skey.) 

its  altered  condition,  still  red  and  only  congested,  but  softened,  with  the 
peritonjeal  coat  shaggy  rather  than  lustrous,  and  tending  to  tear  easily,  it 
is  clear  that  reduction  will  not  be  effected  by  manipulation  only.  If  the 
distension  is  due  to  flatus,  punctures  may  safeh"  be  made  with  a  ver}-  fine 
hj^drocele  trocar.  Where  fluid  fascal  matter  is  present  the  above  step  is 
dangerous,  and  a  small  incision,  carefull}-  closed  by  Lembert's  sutures, 
the  inversion  being  thoroughly  carried  out,  will  give  the  best  results. 
Where  the  intestine  is  much  congested  and  softened,  though  not  yet 
gangrenous,  or  where  the  surgeon  has  not  skilled  assistance  and  all  the 
aids  of  modern  surgery  ready  to  his  hand,  he  had  better  leave  the  intes- 
tine in  the  sac  after  a  free  division  of  the  stricture.*    This  method,  while 


*  This  will  all  gradually  and  slowly  return  into  the  peritoujeal  cavity.     On  this  point 
the  following  case  by  South  (Chelius's  Surgery,  vol.  ii.  p.  40)  is  of  interest : — "  I  know  by 


STRANGULATED  IN(;U1XAL   HERNIA.  47 

uiiclei'  the  above  conditions  tlie  safer,  prevents,  of  course,  any  attempt 
at  relieving  the  patient,  at  one  operation,  by  a  radical  cure. 

During  any  prolonged  manipulation  of  the  intestines  these  should  be 
kept  covered  as  much  as  possible  by  iodoform  or  plain  sterile  gauze 
wrung  out  of  hot  normal  saline  solution.  It  is  wise  also  that  the  patient 
should  be  well  under  the  anaesthetic  now,  and  breathing  quietly.  If 
vomiting  occur,  the  surgeon  must  wait,  keeping  up  pressure  on  what  he 
has  reduced.  When  the  intestine  is  all  reduced,  any  ligatured  stumps 
of  omentum  are  returned,  and,  if  the  condition  of  the  patient  admit  of 
it,  the  sac  is  detached,  one  of  the  methods  of  radical  cure  given  at  pp.  63 
to  79  made  use  of,  the  precautions  as  to  the  cord  and  other  points  given 
at  p.  62  being  carefully  followed. 

Ln  this,  as  in  other  operations,  the  wound  should  be  carefully  sponged 
with  mercury  perchloride  solution  (i  in  4000),  and  left  exposed  as  little 
as  possible,  especially  the  parts  near  the  opening  into  the  peritonjeum. 

In  providing  drainage  after  an  operation  on  a  large  inguinal  hernia, 
where  the  parts  have  been  much  handled  either  before  or  during  the 
operation,  it  is  well  worth  while  to  bring  the  lower  end  of  a  drainage- 
tube  out  at  the  lower  part  of  the  freshly  sterilised  scrotvmi,  by  means 
of  a  counter-puncture  there,  thus  ensuring  efficient  escape  of  the 
discharges,  and  syringing  out  of  the  wound  if  needful. 

After  thus  considering  the  chief  points  in  the  operation,  it  remains  to 
draw  attention  to  some  special  points  connected  with  inguinal  hernia. 

I.  Varieties. — In  addition  to  the  oblique  and  direct  varieties,  both  of 
which  are  acquired,  there  are  some  others  of  much  practical  importance 
— e.i/.,  («)  The  congenital.  The  tubular  process  of  peritonaeum  is  open 
from  abdomen  to  fundus  scroti,  and  the  contents  lie  in  contact  with  the 
testis.  (/>)  Hernia  into  the  funicular  process  of  peritonaeum.  Here  the 
tubular  process  of  peritonteum  is  divided  into  a  shut  vaginal  sac  below 
and  an  open  funicular  process  above.  Into  the  latter  the  contents 
descend,  but  are  not  in  absolute  contact  with  the  testis,  (c)  Hour-glass 
contraction  of  the  sac.  Here  the  tubular  process  is  open  as  in  («),  but 
an  attempt  at  closure  has  brought  about  a  constriction  which  may  be 
at  the  external  abdominal  ring  or  lower  down  in  the  scrotiim.  If  the 
contents  pass  through  this  constriction,  and  get  low  enough,  they  will 
be  in  actual  contact  ■\^•ith  the  testis,  (d)  Encysted  hernia  of  the  tunica 
vaginalis.  Here  the  funicular  process  is  closed  at  its  upper  extremity — 
i.e.,  at  either  ring  or  in  the  canal — and  open  below  to  the  testicle.  The 
hernial  protrusion  as  it  comes  down  either  ruptures  this  septum  (when  of 
sudden  descent),  or  gradually  inverts  it.  or  comes  down  behind  it.     These 

experience  that  if  strangulation  be  relieved,  it  is  of  little  consequence  how  much  intes- 
tine be  down.  In  reference  to  this  point,  I  recollect  the  lar^i^est  scrotal  rupture  on  which 
I  have  operated,  and  in  which,  before  the  division  of  the  stricture,  there  was  at  least  half 
a  yard  of  bowel  down,  filled  with  air ;  and,  after  the  stricture  had  been  cut  through, 
at  least  as  much  more  thrust  through,  so  that  I  almost  despaired  of  getting  any  back  ; 
yet,  after  a  time,  I  returned  the  whole.  To  my  vexation,  however,  next  morning  I  found 
that  my  patient  had  got  out  of  bed  to  relieve  himself  on  the  chamber-pot.  and.  as  might 
be  expected,  the  bowel  had  descended,  and  in  such  quantity  that  the  scrotum  was  at 
least  as  big  as  a  quart  pot.  and  the  vermicular  motion  of  the  intestine  was  distinctly 
seen  through  the  stretched  skin.  Nothing  further  was  done  than  to  keep  the  tumour 
raised  to  the  level  of  the  abdominal  ring,  and  by  degrees  it  returned,  and  the  patient 
never  had  an  untoward  symptom." 


48  OPERATIONS  ON  THE   ABDOMEN. 

cases  are  rare,  but  may  be  puzzling  when  they  occur,  as  the  operator  has 
more  than  one  layer  of  peritongeum  to  incise  before  reaching  the  contents. 
That  the  above  varieties  have  an  importance  bej^ond  that  of  anatomical 
puzzles  is  shown  by  the  fact  that  in  (/>),  (c),  and  (d)  strangulation  may 
be  very  acute  and  urgent.  Again,  though  the  defect  is  a  congenital  one, 
the  hernia  does  not,  in  many  cases,  make  its  appearance  till  the  patient 
has.  in  early  adult  life,  been  subjected  to  some  sudden  strain.  Finally, 
in  these  cases  an)^  prolongation  of  the  taxis  will  be  not  onl}^  futile,  but 
actuall}"  dangerous,  owing  to  the  tightness  of  the  strangulation  and  the 
facility  with  which,  from  the  delicac}"  of  its  adhesions,  the  sac  may  be 
separated  or  burst. 

II.  Bed'udion  en  Masse,  and  Allied  Conditions. — These  have  been 
chiefly  met  with  in  inguinal  hernise  owing  to  the  loose  connections  of 
the  sac  and,  sometimes,  to  the  force  used  in  attempts  at  reducing  large 
sj^ecimens.  Strangulation  may  persist  after  {a)  displacement,  or  (6) 
rupture  of  the  sac.  In  the  former,  the  sac,  still  strangling  its  contents 
at  its  neck,  is  displaced  bodily  between  the  peritoneeum,  usually,  and 
extra-peritongeal  fascia.  In  the  latter  the  sac  is  rent,  usually  close  to 
its  neck  and  at  its  posterior  aspect,  and  some  of  its  contents  are  thrust 
through  into  the  extra-peritongeal  connective  tissue.  The  chief  evidence 
of  these  accidents  is  :  though  the  swelling  has  disappeared,  perhaps 
completely,  this  has  taken  place  without  the  characteristic  jerk  or 
gurgle.  On  close  examination,  though  the  bulk  of  the  hernia  is  gone, 
some  swelling,  often  tender,  is  usuall}^  to  be  made  out,  deep  down,  in  the 
neighbourhood  of  the  internal  ring.  Above  all,  the  s3'mptoms  persist, 
perhaps  in  an  intensified  form. 

The  treatment  is  immediate  exploration  of  the  inguinal  canal  and  the 
internal  ring.  If  the  cord  is  exposed,  the  whole  sac  has  probably  been 
detached.  If  any  of  the  sac  is  left  above,  a  rent  in  it  should  be  sought 
for.  Supposing  the  index  finger,  passed  through  the  internal  ring,  fail 
to  find  an}'  swelling,  aided  by  pressure  from  above,  a  vertical  incision 
must  be  added  to  the  upper  end  of  the  oblique  one,  and  the  neighbour- 
hood of  the  internal  ring  explored.* 

III.  Betained  Testis  sionulating  Hernia. — Such  a  testis,  when  inflamed, 
may  closel}'  simulate  strangulated  hernia.  A  testis,  perhaps,  has  never 
descended  ;  a  truss  has  been  worn  and  laid  aside.  The  patient  presents 
himself  with  a  tender  swelling  in  one  groin,  with  indistinct  impulse. 
The  abdomen  is  tense  and  full,  constipation  is  present,  and  perhaps 
vomiting  of  bilious  fluid.  Such  a  swelling  should  be  explored  and  the 
testis  removed,  as  it  is  certain,  later  on,  to  cause  serious  trouble,  even  if 
the  present  urgent  symptoms  subside  with  palliative  treatment.  In 
other  cases  a  retained  testis  may  draw  down  an  adherent  loop  of  intes- 
tine which  ma}'  become  actually  strangled. f 

STRANGULATED     UMBILICAL     HERNIA. 

Two  distinct  forms  of  strangulated  hernia  will  be  met  with  here.  One, 
more  rare,  is  of  small  size,  with  a  single  knuckle  of  intestine  acutely 

*  As  this  will  probably  involve  abdominal  section,  the  steps  given  later  should  be 
referred  to. 

t  For  fuller  information  on  these  matters  I  would  refer  my  readers  to  The  Diseases  of 
the  Male  Orr/am  of  Generation,  chapter  ii.  p.  72. 


STRANGULATED  UMBILICAL  HERNIA.  49 

strangled  in  the  navel-cicatrix.  The  other,  the  more  common,  is  often 
huge,  its  contents  mixed,  intestine  both  large  and  small,  and  omentum. 
Such  herniiie  soon  become,  in  part  at  least,  irreducible ;  when  in  this 
condition,  any  unwise  meal  may  readily  bring  about  obstruction,  a 
condition  requiring  much  care  to  tell  from  strangulation.*  In  other 
cases  a  large  irreducible  hernia  may  easily  become  strangulated  from 
the  descent  of  some  additional  loop  of  bowel.  The  adequate  fitting 
of  a  truss  is  often  a  matter  of  much  difficulty  here,  owing  to  the  large 
size  of  the  abdomen,  the  presence  of  adherent  omentum,  and,  frequently, 
of  an  habitual  cough. 

Practical  Points  before  Operatioii. — (a)  The  sac  usually  communicates 
directly  with  the  general  peritonteal  cavity  by  a  large  opening.  (/3)  The 
contents  are  not  only  mixed,  but  of  long  standing,  and  often  adherent. 
(7)  The  patients  are.  often  advanced  in  life,  obese,  flabby,  and  not 
infrequently  the  subjects  of  chronic  bronchitis.  (5)  The  coverings  are 
ill  nourished  and  slough  easily. 

Operation. — In  view  of  the  delicacy  of  the  skin  and  the  intertrigo 
which  is  often  pi'esent,  the  cleansing  must  be  thorough  but  gentle.  An 
anesthetic  having  been  administered,  an  incision  two  to  three  inches  long 
is  made  over  the  lowerf  part  of  the  swelling  in  the  middle  line,  the  hernia 
being  pushed  upwards  to  facilitate  this.;!:  The  thinness  of  the  cover- 
ings must  be  remembered.  Search  should  be  made  for  any  constricting 
bands  of  fibres  outside  the  sac.  If  it  be  needful,  the  sac  must  be  opened, 
with  the  knife  held  horizontally,  and  slit  up,  care  being  taken  now  and 
throughout  the  operation,  in  cases  of  large  herniee,  that  protrusion  of 
intestine  be  prevented  by  the  means  given  a  little  later.  The  contents 
having  been  examined,  any  intestine  is  gently  displaced  upwards,  while 
the  surgeon  turns  the  curved  surface  of  a  Key's  director  over  the  lower 
edge  of  the  opening,  and,  guiding  the  hernia-knife  on  this,  di\4des  the 
constricting  edge  downwards.  If  sufficient  space  is  not  given,  the  down- 
ward nick  may  be  repeated,  or  the  director  turned  against  the  lateral  or 
upper  aspects  of  the  ring,  and  fibres  here  also  divided. 

Adhesions  of  the  contents  of  the  sac  are  not  infrequently  met  with. 


*  Amongst  the  most  important  points  will  be  the  vomiting,  whether  early  in  onset, 
constant,  and  showing  signs  of  becoming  fssculent,  and  the  constipation,  whether 
absolute,  even  to  the  passage  of  flatus.  In  doubtful  cases  the  rule  should  be  to  operate. 
"  The  risk  of  operating  on  a  hernia  which  is  inflamed  and  not  easily  reducible  is  very 
small  in  comparison  with  the  risk  of  leaving  one  which  is  inflamed  and  strangulated  ; 
and  even  if  you  can  find  reasons  for  waiting  it  must  be  ^^•ith  the  most  constant  over- 
sight, for  an  inflamed  and  irreducible  hernia  may  at  any  time  become  strangulated,  and 
will  certainly  do  so  if  not  relieved  by  rest  and  other  appropriate  treatment"  (Sir  J. 
Paget,  loc.  supra  cit.,  p.  106). 

j-  The  lower  part  is  here  recommended  because,  in  Mr.  "Wood's  words  (^Intern.  En^i/cL 
of  Surg.,  vol.  v.  p.  1165),  "the  point  of  strangidation  in  an  adult  umbilical  hernia  is 
most  frequently  at  the  lower  part  of  the  neck  of  the  sac,  where  the  action  of  gravity,  the 
dragging  weight  of  the  contents,  and  the  superincumbent  fat,  together  with  the  pressure 
and  weight  of  the  dress  or  an  abdominal  belt,  combine  to  press  downwards  upon  the 
sharp  edge  of  the  abdominal  opening.  It  is  here  that  adhesions  and  ulceration  of  the 
bowel  are  most  frequently  found,  and  here  the  surgeon  must  search  for  the  constriction 
in  cases  of  strangulation."    An  incision  here  also  gives  better  drainage. 

X  If  the  surgeon  intends  to  attempt  a  radical  cure,  and  if  the  skin  is  diseased,  much 
thickened  with  old  abrasions,  he  should  remove  this  area  by  two  elliptical  incisions. 
VOL.   II.  4 


50  OPERATIONS  ON  THE  ABDOMEN. 

If  they  are  very  close  and  dense,  and  if  the  condition  of  the  patient  is 
unsatisfactory,  and  if  the  surgeon  be  short-handed,  he  should  be  con- 
tent with  a  free  division  at  one  or  two  places  of  the  consti'icting  ring, 
and  with  reducing  an}^  portion  of  intestine  that  has  clearly  only  recently 
come  down,  and  leave  the  rest  undisturbed. 

A  complication  of  large  umbilical  hernige  is  thus  well  descrilied  by 
Mr.  Wood  (loc.  sup-a  cit.,  p.  1 168) : 

"  In  corpulent  persons,  in  whom  the  operation  has  been  delayed  until 
peritonitis  has  begun,  the  operator  has  frequently  to  contend  with  a  rush 
of  bowels  out  of  the  abdomen.  This  should  be  restrained  bj^  receiving 
them  in  warm  towels*  wet  with  carbolic  lotion,  and  applying  pressure 
by  the  hands  of  assistants.  If  it  can  be  managed,  all  the  operative 
proceedings  within  the  sac  should  be  done  before  such  a  rush  occurs  ; 
but  if  a  cough,  or  vomiting,  or  anaesthetic  difficulty  occurs  at  this 
juncture,  this  is  sometimes  impossible,  and  the  surgeon  is  compelled  to 
do  the  best  he  can.  In  such  cases  the  operation  becomes  a  formidable 
one  indeed,  and  is  comparable  only  to  laparotomy  under  conditions  of 
distension  of  the  intestines.  The  bowels  and  omentum  should  always, 
if  possible,  be  kept  in  the  warm  wet  towels,  and  not  indiscriminately 
handled  by  the  assistants,  whose  arms  should  be  bared  and  well  purified 
with  carbolised  lotion.  The  intestines  should  always  be  returned  before 
the  omentum,  which  should,  if  possible,  be  spread  outf  over  them  before 
the  stitches  are  applied." 

All  the  intestine  and  the  remains  of  the  omentum,  carefully  ligatured, 
having  been  returned  if  possible,  the  surgeon  now,  if  the  patient's  con- 
dition admits  of  it,  removes  the  redundant  sac  and  skin.  The  opening 
into  the  abdominal  cavity  is  closed  in  the  following  manner : — The  sac 
is  carefully  separated  all  round  till  its  neck  is  cleared,  the  redundant 
part  is  cut  away,  and  the  peritonreum  closed  b}^  means  of  a  continuous 
suture  of  fine  silk.  The  edges  of  the  ring  are  now  drawn  firmly  together 
in  the  same  wa}'  by  means  of  a  continuous  silk  suture ;  if  and,  finally, 
the  skin  edges  are  united  with  horsehair  or  fishing-gut. 

It  will  be  seen  from  the  above  account  that  three  methods  may  be 
pursued  in  the  reduction  of  a  strangulated  umbilical  hernia:  (i)  The 
division  of  the  stricture  outside  the  sac  (p.  35).  Where  the  surgeon  is 
short-handed,  this  should  always  be  tried,  but  is  rarely  successful  here. 
(2)  If  the  sac  has  to  be  opened,  the  opening  is  made  as  small  as  possible, 
and  the  ring  freely  divided  at  one  or  two  points,  but  the  contents 
disturbed  as  little  as  possible,  any  recently-descended  intestine  being 
returned,  but  thickened  omentum  and  adherent  intestine  (esiDCcially 
large)  being  left  undisturbed.     (3)  Free  opening  of  the  sac,  examination 

*  Large  squares  of  iodoform  gauze  wrung  out  of  hot  sterile  salt  solution  are  to  be 
preferred. 

f  Mr.  Wood  prefers  leaving  the  edge  of  the  omentum  so  arranged  as  to  become 
adherent  to  the  lower  margin  of  the  hernial  opening,  so  as  to  prevent,  if  possible,  any- 
future  protrusion,  to  tying  it  and  cutting  it  short. 

J  Mr.  Barker  (^lirif.  Med.  Jmirn.,  1885,  vol.  ii.  p.  iioi)  advises  the  use  of  a  double 
row  of  sutures — the  first  as  given  above,  to  unite  the  edges  of  the  ring ;  the  second,  to 
give  extra  strength  to  the  scar,  are  passed  through  the  anterior  layer  of  the  sheath 
of  the  rectus  on  each  side,  at  about  one-third  of  an  inch  from  the  edge  of  the  ring. 
On  these  being  brought  together,  a  considerable  fold  of  fibrous  tissue  is  inverted  and 
brought  into  contact  in  the  middle  line,  over  the  first  row  which  closed  the  ring. 


STRANGULATED  OBTUEATOE  HERNIA.  5  I 

and  separation  of  its  contents,  return  of  all  intestine,  and  of  omentum 
after  ligature  and  resection. 

While  the  third  of  these  courses  has  the  great  advantage  of  leaving 
the  patient  permanently  in  a  more  satisfactory  condition,  as  it  admits  of 
something  like  a  radical  cure,*  the  surgeon  can  only  rightly  decide 
between  this  and  the  second  course  hy  a  careful  consideration  of  each 
case.  The  following  points  may  aid  in  judiciouslj'  selecting  either 
operation: — (i)  The  size,  long  standing,  previous  attacks  of  incarcera- 
tion and  obstruction  of  the  hernia,  all  these  tending  to  bring  about 
adhesions  and  alterations  in  the  parts.  (2)  The  condition  of  the 
patient — viz.,  the  degree  of  flabby  fatness,  chronic  bronchitis,  probable 
renal  and  hepatic  disease,  amount  of  depression  by  vomiting  and  pain. 
(3)  The  facilities  for  carr^nng  out,  during  the  operation  and  later,  strict 
antiseptic  precautions.  (4)  The  presence  of  the  skilled  help  so  essential 
in  these  cases.  (5)  The  way  in  which  the  an;esthetic  is  taken.  (6)  The 
amount  of  experience  of  the  ojDcrator.  Thus  a  hospital  surgeon, 
frequently  operating  and  ^^•ith  all  instruments  and  assistance  at  hand, 
may  readily  incline  to  one  course,  while  the  other  may  as  wisely  be 
followed  by  a  surgeon  who  has  to  operate  under  very  different 
circumstances.! 

STRANGULATED     OBTURATOR     HERNIA. 

This  form  of  hernia  has  occurred  too  frequently  to  be  entirely  passed 
over.  It  maj^  be  so  readily  and  fatally  overlooked  that  a  few  words  on 
its  diagnosis  will  not  be  out  of  place. 

(i)  Position  of  the  swelling.  This  appears  in  the  thigh  below  the 
horizontal  ramus  of  the  pubes,  behind  and  just  inside  the  femoral 
vessels,  behind  the  pectineus,  and  outside  the  adductor  longus.  (2)  On 
careful  compai-ison  of  the  outline  of  Scarpa's  triangles,  a  slight  fulness 
is  found  in  one  as  compared  with  the  hollow  in  the  other.  (3)  Pain 
along  the  course  of  the  obturator  nerve,  down  the  inner  side  of  the 
thigh,  knee,  and  leg.  (4)  Persistence  of  symptoms  of  strangulation, 
±\\e  other  rings  being  empty  or  occupied  by  reducible  hernia.  (5)  A 
vaginal  or  rectal  examination. 

Operation. — Two  different  ones  present  themselves  :  (i.)  by  cutting 
down  on  the  sac,  as  in  other  hernice  ;  (ii.)  by  abdominal  section,  and 
withdrawing  the  loop  from  within. 

(i.)  The  parts  having  been  duly  cleansed  and  slightly  relaxed,  an 
incision  is  made   parallel  to  and  just   inside  the  femoral  vein. J     The 

*  It  will  be  remembered  that  it  is  not  so  essential  to  try  and  ensure  a  radical  cure 
in  the  usual  subjects  of  umbilical  hernia  as  in  children  and  young  male  adults,  with 
the  prospect  of  a  long  and  active  life  before  them. 

f  Mr.  Clement  Lucas  (^C'lin.  Soc.  Trans.,  vol.  xix.  p.  5)  advocated  more  radical 
measures,  such  as  excision  of  the  sac  and  redundant  skin,  with  suture  of  the  ring,  in 
.all  cases  of  umbilical  hernia.  Two  successful  cases  are  recorded,  both  excellent 
instances  of  this  treatment,  and  one  of  especial  interest,  as  the  patient  had  bei'ii 
previously  thrice  tapped  for  ascites,  and  the  operation  allowed  three  pints  and  a  half 
.of  fluid  to  escape. 

X  Mr.  Birkett  (Joe.  supra  cit.,  p.  830)  says  the  incision  "  may  commence  a  little  above 
Poupart's  ligament,  at  a  point  midway  between  the  spine  of  the  pubes  and  the  spot 
-where  the  femoral  artery  passes  over  the  ramus  of  that  bone." 


52  OPERATIONS  ON   THE  ABDOMEN. 

saphenous  opening  being  probably  exposed  in  part,  the  fascia  over  the 
pectineus  and  the  fibres  of  this  muscle  having  been  divided  transversely 
for  one  and  a  half  or  two  inches,  the  obturator  muscle  covered  by  its 
fascia  and  some  fattj'  cellular  tissue  is  next  defined,  and  the  hernial  sac 
probably  now  comes  into  view,  either  between  the  muscle  and  the 
pubes,  or  between  the  fibres  of  the  muscle.  If  the  case  is  a  recent  one, 
attempts  are  now  made  to  reduce  the  hernia  without  opening  the  sac. 
If  the  sac  has  to  be  opened,  and  an}*  constriction  divided,  the  knife 
should  be  turned  either  upwards  or  downwards,  the  latter  being  the 
easier  if  any  constricting  fibres  intervene  between  the  sac  and  the 
bone.  As  the  obturator  vessels  lie  usually  on  one  side  or  the  other, 
a  lateral  incision  must  be  avoided. 

Care  must  be  taken  to  keep  the  femoral  vessels  drawn  outward  with  a 
retractor,  while  any  branches  of  the  obturator  or  anterior  crural  nerve 
are  drawn  aside  with  a  l)lunt  hook,  the  same  precaution  being  taken 
with  the  saphena  vein. 

When  by  the  passage  of  the  little  finger  into  the  abdomen  it  is 
certain  that  the  intestine  is  reduced,  if  the  condition  of  the  patient 
admits  of  it,  the  sac  is  separated  and  ligatured  close  to  the  thyroid 
foramen  and  removed.  Drainage  must  be  provided  with  aseptic  horsehair 
or  a  fine  tube. 

(ii.)  The  operation  of  abdominal  section  will,  perhaps,  be  more  fre- 
quently performed  in  the  future. 

An  obturator  hernia  was  thus  reduced  by  Mr.  Hilton  in  a  case  which  simulated 
intestinal  obstruction.  Some  empty  intestine  being  found  and  traced  downwards,  led 
to  the  detection  of  an  obturator  hernia,  which  was  reduced  by  gentle  traction  aided  by 
firm  pressure  made  deeply  in  the  thigh.  The  patient,  who  was  not  operated  on  till  the 
eleventh  day,  died  of  rapid  peritonitis. 

Sir  J.  E.  Erichsen  briefly  mentions  a  case  operated  on  by  this  means  in  1884  by  Mr, 
Godlee.  The  hernia  was  reduced  without  dilficulty.  but  the  patient,  who  was  much 
collapsed  at  the  time,  died  in  about  twenty-four  hours. 

Question  of  the  advisability  of  reducing  Strangulated  Hernia  by- 
Abdominal  Section. 

This  question  having  arisen  here  may  be  dealt  with  once  for  all. 
Cases  will  occur  from  time  to  time,  such  as  Mr.  Hilton's  {loc.  supra  cit.), 
in  which,  evidence  of  acute  intestinal  strangulation  existing  and  no- 
hernia  being  detected  externallv,  on  the  abdomen  being  opened  the 
cause  will  be  found  to  be  a  piece  of  a  small  intestine  nipped  in  part  of 
its  circumference,  probably  in  either  one  of  the  femoral  or  obturator 
rings.  Still  more  rarely,  a  surgeon  may  find  such  difficulty  in  reducing 
an  obturator  hernia  from  without,  that  he  feels  himself  driven  to  resort 
to  abdominal  section.  In  such  a  case  an  incision  should  be  made  along 
the  corresponding  linea  semilunaris,  and  brought  as  Ioav  down  as  possible. 
When  the  abdomen  is  opened,  if  there  is  any  difficulty  in  withdrawing 
the  gut,  the  intestines  should  be  pushed  upwards  out  of  the  pelvis,  and 
the  neighbourhood  of  the  ring  shut  off  with  sponges  or  iodoform  gauze 
tampons,  while  the  condition  of  the  strangled  loop  is  inspected,  and  this 
either  reduced,  or  treated  by  resection,  or  hj  the  making  of  an  artificial 
anus,  according  to  the  condition  of  the  patient  and  the  surroundings  of 
the  operator.  vSome  years  ago  it  was  suggested  that  it  should  be  the 
rule  to  reduce  hernife,  and  perform  the  radical  cure  by  abdominal  section. 
Thus,  at  the  meeting  of  the  British  Medical  Association  in  1891  (Brit.. 


RADICAL  CURE  OF  HERNIA.  53 

Med.  Juurn.,  Sept.  26,  1891),  this  question  was  discussed,  tlie  late  Mr. 
Lawson  Tait  introducing  the  subject.  As  might  be  expected,  the  pro- 
posal to  abandon  the  old  operation  and  treatment  by  median  abdominal 
section  met  with  no  support  from  those  surgeons  who  know  anything  of 
operations  for  strangulated  hernia  in  hospital  practice,  especially  in  males. 
Save  in  the  rarest  cases,  such  as  those  belonging  to  the  category  I  have 
mentioned,  such  a  step  is  to  be  condemned  in  the  strongest  terms,  for 
the  following  reasons:  (i)  Operations  for  relief  of  strangulated  hernia 
must  sometimes  be  performecl  by  general  practitioners.  The  old  and 
well-established  operation  is  one,  j^^"''  se,  of  but  slight  severity,  and  one 
that  usually  can  be  kept  extra-peritonfeal  by  an  operator  of  ordinary 
skill  and  of  average  anatomical  knowledge.  Those  who  would  substi- 
tute abdominal  section  forget  that,  however  safe  they  may  consider 
themselves,  with  their  especial  experience,  to  be  in  preventing  pe/77o7r/fts 
— a  ver}-  different  standpoint  from  that  of  a  general  practitioner — 
neither  they  nor  anyone  else  can  prevent  the  shock  which  goes  with 
intra-peritonaeal  operations,  a  complication  which  is  certainly  to  be 
avoided  in  patients  exhausted  by  a  strangulated  heniia.  (2)  The 
reduction  of  the  intestine  which  is  spoken  of  as  so  easy  after  abdominal 
section  by  those  who  advocate  this  method,  is  liable  to  be  prevented  by 
adhesions  to  the  sac,  &c. ;  when  such  exist — and  no  one  can  foretell  this 
point — the  sac  must  be  explored  in  the  usual  way.  (3)  There  is  a  very 
grave  risk  that  the  intestine  is  tightly  nipped,  and  often  may  give  way 
when  pulled  upon  through  a  median  incision.  Those  who  advocate 
abdominal  section  will  say  that  the  resulting  extravasation  can  be  met 
by  flushing,  &c.  It  will  be  well  for  all  such  to  remember  the  following 
advice,  tersely  put  by  Sir  W.  Bennett  (Clin.  Led.  on  Hernia,  p.  122): 
"  Let  it  be  noted  that  it  is  generally  far  more  easy  to  soil  the  peritonaeum 
than  to  cleanse  it."  The  same  surgeon  points  out  (ibidem,  p.  121)  that 
the  fluid  found  in  the  sac  of  hernia,  when  strangulation  has  long  existed, 
is  sometimes  dark  and  ill-smelling,  though  no  lesion  may  be  apparent 
in  the  gut  itself.  B3'  an  ordinary  herniotomy  such  fluid  is  thoroughly 
drained  away  from  the  peritonaeal  cavity,  and  any  such  intestine  is 
cleansed  before  it  is  put  back,  or  otherwise  appropriately  dealt  with, 
(4)  All  operating  surgeons  are  agreed  that,  whenever  the  condition  of 
the  patient  admits  of  it,  an  operation  for  strangulated  hernia  should  be 
com])leted  by  giving  the  patient  at  least  a  chance  of  radical  cin^e.  I 
am  distinctly  of  opinion  that  no  intra-])eritonasal  operation  yet  described 
will  secure  radical  results  in  inguinal  heniiae.  (5)  Those  who  think 
they  are  improving  matters  by  substituting  abdominal  section  for  the 
old-established  herniotomy,  object  to  the  latter  on  account  of  its  ten- 
dency to  weaken  the  abdominal  wall  by  the  incision  made  to  reach  and 
relieve  the  constriction.  Such  advocates  forget  the  criticism  pithily 
put  forward  during  the  above  discussion  by  Mr.  Keetley,  that  treatment 
of  herniee  by  abdominal  section  created  two  potential  hernial  apeitures 
where  there  was  originally  but  one. 

RADICAL    CURE    OF    HERNIA. 

Before  describing  the  diflferent  methods,  the  following  points  claim 
attention ;  and  while  the  improvements  of  modern  surgery  have  esta- 
blished radical  cure  on  a  sound  scientific  basis,  many  questions  remain 


54  OPERATIONS  OX  THE  ABDOMEN. 

still  iTiidecided.  The  chief  of  these  are  :  (i)  The  justifiability  of  the 
operation.  (2)  The  use  of  the  terms  "  radical  cure  "  and  "  jjermanency 
of  the  cure."  (3)  The  earliest  age  at  which  the  operation  is  advisable 
in  children.  (4)  The  advisabilit}'  or  need  of  wearing  a  truss  afterwards. 
(5)  The  best  material  for  suture.     (6)  The  best  form  of  operation. 

(i)  The  Justifiability  of  the  Operation. — Before  we  can  answer  this 
in  the  affirmative  we  must  be  able  to  honestly  feel  that  the  operation  is 
safe,  (a)  as  regards  the  fatieni's  life,  (8)  as  regards  the  testicle.  Only 
those  surgeons  who  have  had  experience  in  operating,  who  are 
thoroughly  acquainted  with  the  needs  of  modern  surgery,  and  who  will 
pay  the  needful  attention  to  every  detail,  can  promise  the  above  safety. 

(a)  The  safety  of  tJie  patient's  life. — The  following  recent  statistics 
show  what  modern  surgery  and  experienced  hands  can  do.  Drs.  Bull 
and  Coley  {Annals  of  Surgery,  vol.  xxviii.,  1898,  p.  604)  have  compiled 
a  list  of  8594  cases  under  the  care,  be  it  noted,  of  well-known  operators, 
with  seventy-eight  deaths,  giving  the  very  low  mortality  rate  of  -g  per 
cent. 

(/3)  The  safety  of  the  testide.—TYna  is  dealt  with  at  p.  62. 

(2)  The  Value  of  the  Term  "  Radical  Cure,"  and  the  Permanence 
of  the  Cure  after  Operation. — Present  results  give  the  promise  of 
great  improvement  here.  A  few  years  ago  some  of  the  best  authorities 
were  not  using  the  term  '•  radical."'  Thus,  Sir  W.  M.  Banks,*  one  of 
the  earliest  and  foremost  workers  on  the  subject,  and  a  writer  who  has 
given  his  results  with  honest  frankness,  considers  the  term  radical  cure 
"  misleading.  It  is  popularly  understood  that  a  patient  upon  whom 
the  radical  cure  has  been  performed  need  never  again  wear  a  truss  nor 
ever  again  be  in  danger  of  his  hernia  coming  down.  This  is,  unfor- 
tunately, far  from  being  the  case.  The  instances  in  which  a  light 
truss  can  be  dispensed  with  are  in  the  minority."  A  few  years  later 
(Brit.  Med.  Journ.,  1893,  vol.  ii.  p.  1044)  he  wrote  somewhat  more  hope- 
fully. Of  168  cases  he  had  traced  for  very  considerable  periods  113  ; 
"of  these  79  remain  quite  sound,  19  are  partial  successes,  and  15 
are  complete  failures."  In  America — where,  as  with  oophorectomy  and 
removal  of  the  appendix,  this  operation  has  been  resorted  to  more  freely 
than  in  this  countrj' — warnings  have  been  given  by  some  of  the  best- 
known  surgeons  that  the  use  of  the  term  "  radical  cure"  may  be  pre- 
mature. Amongst  the  chief  of  these  has  been  Dr.  W.  T.  Bull,t  Surgeon 
to  the  Hospital  for  the  Euptured  and  Crippled,  of  New  York.  Dr.  Bull 
has  collected  137  cases  operated  on  for  radical  cure  in  which  a  relapse 
had  taken  place,  and  he  adds  that  these  relapsed  cases  ••  probably 
represent  but  a  small  proportion  of  those  operated  on." 

Mr.  JNIacready.  Surgeon  to  the  City  of  London  Truss  Society,  writes 
the  following  weighty  words  on  what  he  calls  the  unsatisfactory  nature 
of  the  evidence  as  to  efficacy  of  the  radical  cvire  (A  Treatise  on  Ruptures, 
p.  234) :  "  The  evidence  brought  forward  by  one  surgeon  after  another 
in  favour  of  these  operations  is  alwajrs  of  the  same  character.  A  number 
of  cases  are  given  in  which  the  operation  has  been  performed,  and  in 
which  the  result  has  been  Avatched  for  periods  varying  usually  from  a 

*  Pamphlet;  Med.  Timts  and  Gciz.,  1884;  Brit.  Med.  Journ.,  Dec.  10,  1887. 
f  N.Y.  Med.  Journ.,  May  30,  1891;  Med.  NeivH,  1890;  Annals  of  Surr/cry,  1893.  vol.  i. 
p.  534  et  mj. 


R.U)ICAL  CURE  OF  HERNIA. 


55 


few  months  to  four  or  five  years.  Very  few  cases  are  under  observation 
so  long  as  five  years ;  for  the  patient  changes  his  residence  or  declines 
to  show  himself.  M.  Terrier  on  one  occasion  wrote  to  twenty-five  old 
patients,  and  received  only  two  replies.  It  must  not  be  supposed  that  a 
patient  is  cured  because  he  does  not  come  for  inspection.  The  relapsed 
cases  at  the  Truss  Society  have  almost  all  been  asked  if  they  have  visited 
the  operator  to  show  him  the  result.  In  the  great  majority  of  cases  they 
prefer  not  to  go  back,  and  very  often,  alas !  express  themselves  as  if  a 

Fig.  II. 


Dissection  of  iiiguinal  canal. 

I,  External  oblique  turned  down.     2,  Internal  oblique.     3,  Transversalis. 

4,  Conjoined  tendon.     5,  Rectus  abdominis  ■with  its  sheath  opened. 

6,  Triangular  fascia.     7,  Cremaster.      (Heath.) 

deception  had  been  practised  upon  them.  It  is  much  to  be  regretted 
that  patients  should  feel  this  reluctance  to  face  the  operator  again,  for 
in  consequence  the  surgeon  is  apt  to  form  too  favourable  an  opinion  of 
the  efiicac}^  of  his  plan.  Sometimes  a  patient,  after  remaining  cured  for 
a  number  of  years,  passes  from  under  observation  and  again  becomes 

ruptured All    that   we    can    say    of  the    operations,    involving 

complete  removal  of  the  sac,  is  that  they  all  give  immunity  to  a  certain 
number  for  a  certain  time." 

AMiile  opinions  like  the  above,  candidly  expressed  by  operators  of  wide 


56  OPEEATIONS  OX  THE  ABD03IEN. 

experience,  will  carry  special  weight  with  all  thoughtful  surgeons,  it  is 
probable  that  the  work  of  the  last  few  years,  and  still  more  that  of  the 
coming  decade,  will  place  the  radical  cure  of  hernia  on  a  firmer  and 
more  satisfactory  basis. 

We  are  now  learning  more  distinctly  the  principles  on  which  this 
operation  is  to  be  conducted.  Two  or  three  methods  have  now  been 
emploj'ed  on  such  a  large  scale,  and  with  such  excellent  results,  that  it 
seems  probable  that  a  permanent  cure  can  be  promised  in  a  large  number 
of  favourable  cases.  Tliis  cpialified  statement  requires  explanation.  By 
a  "  permanent  cure,"  I  mean  a  cure  which  will  last  a  lifetime.  By 
•'  favourable  cases,"  I  mean  children,  young  subjects,  hernise  of  moderate 
size,  where  the  rings  and  canal  are  still  present  and  not  stretched  and 
converted  into  one  large  direct  gap  into  -s^'hich  the  tips  of  two  or  three 
fingers  can  be  easily  placed ;  cases  where  the  patients  operated  on  have 
sense  enough  to  give  the  newly  repaired  structures  sufficient  rest  for 
their  consolidation,  and  where,  if  they  must  follow  employment  or 
exercise  that  involves  much  straining,  they  will  give  the  parts  the 
support  of  a  truss  of  light  pressure  or  a  belt*  (vide  infra).  If  this  is 
not  done  we  shall  see,  if  cases  are  carefully  followed  up  and  candidly 
reported,  that  radical  cures  will  not  last  a  lifetime,  and  that  the  term 
will  have  to  be  largely  replaced  by  the  following,  according  to  the 
degree  of  cure  obtained — viz.,  "  complete  successes,"  "  partial  successes," 
"  complete  failures." 

Since  Bassini  published,  in  1888,  the  description  of  his  operation,  this 
method,  either  as  first  described  or  modified  in  some  slight  degree,  has 
become  more  and  more  popular,  and.  at  the  present  time,  its  adoption 
may  be  said  to  be  almost  universal.  Drs.  Bull  and  Coley  (Joe.  siqrra  cit.) 
have  given  the  results  of  the  operations  by  Bassini's  method  which 
they  have  performed  up  to  September  1898.  In  all  there  are  343  opera- 
tions with  only  three  relapses.  It  is  true  that  some  of  these  operations 
had  been  done  quite  recently,  and  the  true  result  in  these  could  not 
therefore  be  finally  decided ;  nevertheless,  since  many  of  the  operations 
had  been  done  over  five  years  before  publication,  the  results,  taken  as  a 
whole,  must  be  considered  very  satisfactory,  and  more  excellent  than 
any  large  collection  of  cases  yet  published. 

Drs.  Bull  and  Coley  also  give  an  analysis  of  360  cases  of  relapse  after 
operations  for  radical  cure,  that  were  seen  at  the  New  York  Hospital 
for  Ruptured  and  Crippled.  In  no  less  than  80  per  cent,  of  the  cases 
relapse  had  taken  place  within  twelve  months  of  the  operation ;  on  the 
other  hand,  in  five  cases  the  period  was  between  ten  and  twenty-two 
years  after  operation. 

It  may  be  said,  therefore,  that  after  one  year  the  chances  of  relapse 
are  not  great,  although  no  absolute  time  limit  can  be  given  after  which 
cure  ma}''  be  said  to  be  absolute. 

From  the  above  it  is  clear  that,  when  consulted  as  to  the  performance 
of  a  radical  cure  by  patients  the  subject  of  hernia,  they  can  be  assured 

*  Many  will  say  that  if  any  truss  or  support  is  worn  afterwards  the  cure  is  not 
radical ;  I  admit  this,  but  reply  that  until  published  series  of  cases  have  been  watched 
for  a  much  longer  period,  we  shall,  as  relapses  may  occur  five  or  eight  years  after 
operation,  do  wisely  to  advise  the  above  class  of  patients  to  support  the  restored  region 
with  a  well-fitting  truss  of  light  pressure,  and  so  bring  about  a  permanent  cure 
instead  of  a  liability  to  relapse. 


EADICAL  CURE  OF  HERNIA.  57 

as  to  the  safety  of  the  operation  and  the  probable  permanence  of  the 
cure  in  favourable  cases  (vide  siqmi).  Furthermore,  it  is  certain  that  if 
a  relapse  should  occur  the  majority  of  patients  will  be  better  off  than 
before  the  operation.  The  protrusion  that  appears  will  be  smaller  than 
the  original  rupture,  more  readily  kept  within  bounds  like  a  bubonocele, 
and  a  truss  will  be  worn  with  greater  comfort.  On  the  other  hand,  if 
suppuration  occur,  and  a  thin- walled  feeble  cicatrix,  sure  to  3'ield 
increasingly  as  years  go  on,  is  the  only  result,  the  outcome  of  the 
operation  may  leave  the  patient  worse  off  than  he  was  before. 

A  question  that  often  arises  relates  to  the  wearing  of  a  truss  and  the 
possibility  of  the  hernia  being  cured  by  this  means  alone. 

The  answer  deciding  between  the  wearing  of  a  truss  and  an  operation 
for  radical  cure  will  depend  greatly  on  the  mind  of  the  surgeon  consulted. 
If  he  is  one  of  those  who  believe  that  this  operation  is  too  indiscrimi- 
nately resorted  to,  he  will  hold  that  no  operation,  save  for  special 
reasons  (vide  Indications  for  Operation),  is  to  be  advised  where  the 
hernia  can  be  kept  up  by  a  truss,  and  that  a  light  and  well-fitting 
truss  is  not  the  bugbear  it  is  too  often  made  out  to  be  by  those  who 
advocate  operation  as  the  rule.  It  would  be  well  if  surgeons  would 
spend  some  of  that  pain  and  trouble  in  ensuring  that  the  ti'uss  fits, 
before  it  is  thrown  aside,  which  they  give  to  inventing  or  modifying 
operations  for  radical  cure,  and  if  patients  would  exert  a  little  more 
trouble  and  pains  in  getting  a  proper  and  well-fitting  truss  at  a  duly 
qualified  instrument-maker's,  instead  of  the  first  cheap  trash  which  they 
see  in  a  chemist's  shop.  I  have  pointed  out  below,  under  the  heading 
Indications  for  Operation,  the  cases  where  this  question  of  wearing  a 
truss  does  not  arise.* 

"When  this  question,  whether  the  wearing  of  a  truss  will  effect  a 
radical  cure,  arises  in  the  case  of  infants  and  children,  these  cases  may 
he  divided  into  the  following  groups.  In  one — and  this  is  the  largest  of 
the  three — the  careful  wearing  of  a  truss  by  a  child  will  permanently 
cure  the  rupture.  In  a  second  group — a  large  one — the  hernia,  though 
not  cured,  will  be  perfectly  controlled  with  very  slight  inconvenience  to 
the  patient.  In  the  third — a  very  small  one — there  is  no  tendency  to 
spontaneous  cure  even  when  a  suitable  truss  has  been  diligently 
worn. 

On  this  follows  naturally  the  next  tjuestion  :  (3)  What  is  the  earliest 
age  at  which  an  operation  should  be  performed  ?  Iklow  1  have 
stated  my  opinion  that  while  it  is  occasionally  justifiable  to  operate  in 
the  second  year  of  life,  where  a  persisting  hernia  is  large,  it  is,  as  a  rule, 
better  to  defer  operation  till  the  age  of  four  or  later.  In  this  connec- 
tion the  following  expressions  of  opinion  by  Mr.  Langton  (Brit.  Med. 
Jouni.,  April  ;9."i899.  p.  472)  may  be  quoted:  ''The  cases  requiring 
operation  are  comparatively  rare,  and  ojieration  should  not  be  recom- 
mended in  infancy."  And  again  :  '-Experience  proves  that  hernia  occurs 
at  an  age  ill  suited  for  operation,  and  that  if  properly  treated  (by  truss) 
it  is  usually  cured  long  before  any  question  of  operation  arises." 

(4)  The  Advisability  or  Need  of  wearing  a  Truss  afterwards. — 
The  tendency  of  the  present  day  to  condemn  offhand  or  to  deprecate 


*  An  ill-fitting  truss  is,  of   convse,  worse  than  useless,  and  may  mat  together  the 
tissues. 


58  OPERATIONS  ON  THE  ABDOMEN. 

strongly  the  use  of  a  triiss  after  an  operation  for  radical  cure  is,  I  think, 
a  great  mistake.  Each  case  must  be  judged  separately,  With  regard 
to  children,  from  an  experience  of  my  cases,  I  think  that  if  the  recum- 
bent position  be  insisted  on  for  three  months  after  the  operation,  so  as 
to  give  the  newly  restored  parts  time  to  consolidate  firmly,  a  truss  will 
not  be  subsequently  required,  so  great  is  the  tendency  to  repair  in  early 
life.  Umbilical  hernise  I  am  inclined  to  make  an  exception.  The  com- 
munication which  has  here  been  closed  has  been  relatively  so  large,  the 
stress  thrown  upon  it  after  repair  in  expiratory  efforts  (as  when  the  child 
cries  every  time  at  the  approach  of  the  surgeon  or  dresser  during  the 
after-treatment)  is  so  direct,  that  the  scar  should,  I  think,  have  support 
for  some  time  in  the  form  of  a  well-fitting  belt.* 

In  adults  the  objection  usually  made  to  a  truss  is  that  its  pressure 
will  produce  absorption  of  the  scar.  While  it  will  be  granted  at  once 
that  any  continuous  pressure  in  the  form  of  a  pad  with  a  strong  spring 
w-ill  tend  to  weaken  and  remove  the  inflammatory  thickening  resulting 
from  the  operation,  I  am  distinctly  of  opinion  that  some  well-fitting 
slight  support  in  the  form  of  a  truss  or  belt  should  be  worn  in  the 
following  cases — viz.,  where  the  abdominal  walls  are  very  fat,  flabby 
and  pendulous  ;  wdiere  there  is  heavy  work  either  done  continuously  or 
by  fits  and  starts ;  where  any  silk  has  worked  out,  or  wdiere  the  wound 
has  healed  by  suppuration  (vide  siqjra,  p.  57)  ;  in  some  cases  where  the 
radical  cure  has  been  done  after  an  operation  for  the  relief  of  strangula- 
tion, and  the  surgeon  has  perhaps  been  hurried,  or  has  operated  at  night ; 
and,  of  course,  in  cases  where  there  is  any  return  of  the  hernia.  Other 
cases  are  umbilical  hernise,  Ijoth  in  adults  and  children,  for  the  reason  I 
have  given  above ;  in  femoral  hernias,  owing  to  the  difficulty,  in  many 
cases,  of  doing  more  than  twisting,  tying,  or  inverting  the  sac  (p.  79), 
and  also  because  the  sex  and  dress  of  the  patient  usuall}^  make  the 
A^-earing  of  a  truss  less  irksome.  On  the  other  hand,  in  early  congenital 
cases,  in  boys,  in  young  adults  without  laborious  work,  or  where  the 
reparative  power  is  good,  where  sufficient  rest  has  been  taken  after  the 
operation,  and  where  primary  union  has  been  secured  and  remains  fii'm, 
no  truss  need  be  worn.  But  the  importance  of  intelligent  supervision 
at  intervals  should  be  insisted  upon. 

The  presence  of  a  cough,  carelessness  about  constipation,  or  a  stricture 
will,  of  course,  be  duly  weighed ;  and  I  may  remind  my  readers  of  a 
warning  vittered  at  p.  55,  that  relapse  may  take  place  as  late  as  four  or 
even  eight  years  after  a  skilfully  performed  operation. 

On  the  other  hand,  it  is  only  fair  to  say  that  the  opinion  on  this 
matter  expressed  by  others  is  widely  divergent  on  some  points  from  that 
given  above.  For  instance,  Drs.  Bull  and  Coley  (loc.  supra  cit.)  say  : 
'•  Personall}^  we  never  advise  a  truss  in  children  after  operation,  and  we 
consider  the  recumbent  position  for  three  months  entirely  vinnecessar}^ 
Our  experience,  based  on  a  series  of  upwards  of  600  cases  of  hernia  in 
children  under  fourteen  years  of  age,  has  shown  that  two,  to  two  and  a 
half  weeks  is  ample  time  for  the  child  to  remain  in  bed.  The  subsequent 
history  of  these  cases  has  been  traced  with  scrupulous  care,  and  some  of 
them  have  been  well  upwards  of  seven  years.  Even  in  adults  we  very 
seldom  advise  a  truss  after  operation.     There  are,  however,  some  cases  in 

*  Any  phimosis  or  cough  should,  of  course,  be  treated. 


RADICAL  CURE  OF  HERNIA.  59 

which  a  permanent  cure  will  be  more  likely  to  be  obtained  if  a  support 
be  worn  after  operation.  Such  cases  are  those  beyond  middle  age,  with 
poorl}'  developed  and  flabby  abdominal  muscles  and  a  superabundance 
of  fat.  We  would  also  include  cases  in  which  the  hernia  is  of  unusual 
size  in  adults  past  middle  life." 

Lockwood  (Hernia,  Hydrocele,  and  Varicocele),  again,  does  not  order 
a  trviss  after  operation,  except  in  cases  in  which  some  support  is  specially 
called  for.  He  says :  "  So  far  as  I  can  see,  it  is  time  enough  to  order  a 
truss  when  signs  of  recurrence  appear.  After  radical  cure  has  been 
done,  relapse  seldom  occurs  suddenly.  When  the  sac  has  been  thoroughly 
obliterated  by  the  operation,  the  hernial  protrusion  has  to  make  for  itself 
a  new  one  ;  this  is  usually  a  slow  process  and  accompanied  by  pain  from 
the  beginning."  This  practice  is  clearly  justified  by  results,  for  Lock- 
wood's  list  of  cases  shows  only  five  relapses  in  ninety-one  cases,  in  periods 
varying  from  six  months  to  seven  years.  It  may  be  noted,  also,  that  in 
each  of  these  five  cases  the  relapse  occurred  within  twelve  months. 

(5)  The  Best  Form  of  Suture. — Though  hitherto  I  have  used  silk,  I 
am  of  opinion  that  kangaroo-tendon,  if  a  suitable  specimen,  duly  sterilised, 
can  be  obtained,  will  be  found  preferable,  and  I  intend  to  make  trial  of 
this  in  future.  Silk  is  most  satisfactory  to  work  with  at  the  time  ;  it  can 
be  obtained  at  once,  it  is  soon  sterilised,  it  is  strong,  and  it  lends  itself 
readily  to  easy  tying  and  a  secure  knot.  But  the  after-result  is,  in  my 
opinion,  less  satisfactory,  owing  to  its  liability  to  come  away,  often 
persistently.  There  is  a  tendency  to  believe  and  teach  that  wherever 
silk  comes  away  after  an  operation,  it  must  always  be  due  to  some 
deficient  sterilisation  of  the  silk,  or  to  some  failure  to  keep  the  wound 
aseptic.  While  these  are  leading  causes,  they  are  not,  I  am  persuaded, 
the  only  ones ;  the  site  and  the  character  of  the  tissues  concerned  play  a 
very  important  part.  Inside  the  peritonasal  cavity,  where  the  ligatm'e 
lies  deep  and  is  surrounded  by  a  serous  membrane,  as  in  an  ovarian 
pedicle,  we  are  certain  our  silk  ligature  will  give  no  trouble ;  in  ligature 
of  the  carotid  or  femoral  artery,  where  the  ligature  also  lies  deep  and  is 
surrounded  by  vascular  structures,  we  have  rarely  trouble  with  our  silk 
ligatures ;  but  here,  where  any  silk  used  lies  comparatively  superficially 
and  embedded  in  fibrous  tissues  such  as  the  conjoined  tendon  or  Poupart's 
ligament,  its  surroundings  are  so  different  that  a  surgeon  need  not 
always  blame  himself  for  deficient  asepsis  or  faulty  tying  when  his  silk 
comes  away.  I  am  aware  that  many  surgeons,  higher  authorities  than 
myself,  claim  that  silk,  wire,  salmon-gut  can  all  be  used  as  buried 
sutures  without  any  further  trouble.  In  a  certain  aiid  large  proportion 
I  know  from  experience  that  silk  can  be  used,  but  in  a  considerable 
number  this  and  the  other  materials  most  certainly  cause  trouble  later 
on.  The  wound  runs  an  aseptic  course,  heals  without  suppuration,  and 
then,  after  a  varying  period,  a  sinus  appears,  and  one  or  more  of  the 
sutures  have  to  be  removed.  Prof.  Macewen  uses  chromicised  catgut, 
prepared  by  himself.  Drs.  Bull  and  Coley,  in  the  paper  referred  to 
above,  used  kangaroo-tendon  in  342  cases,  and  though  the  interval 
between  the  date  of  operation  and  that  of  publication  is  in  very  many  of 
them  far  too  brief  for  the  cure  to  deserve,  in  my  opinion,  the  term 
"  radical,"  the  constancy  with  which  primary  \niion  was  secured  speaks 
very  strongly,  I  think,  for  the  use  of  kangaroo-tendon  in  preference  to 
silk. 


60  OPERATIONS  OX  THE  ABDOMEN. 

Indications. — -The  following  are  given  only  as  types  of  appropriate 
cases.     Many  others  will  suggest  themselves  : 

i.  Cases  of  irreducible  hernia  where  other  treatment  has  failed,  where 
an  active  life  is  interfered  with,  or  where  attacks  of  inflammation  have 
occurred,  or  strangulation  is  threatened.  Subjects  of  inguinal  hernia  with 
adherent  omentum  are  never  really  safe,  esjDecially  if  of  active  life  :  from 
this,  however,  they  are  usually  debarred.  Femoral  hernias  containing 
irreducible  omentum  should  also  be  operated  on.  These  hernioe  are 
difficult  to  fit  with  trusses  ;  the  omentum  keeps  the  ring  open,  and  thus 
paves  the  way  for  the  descent  of  bowel  on  any  sudden  exertion.  AVhere 
irreducible  hernise  are  small,  and  the  adhesions  easily  separated,  great 
relief  will  be  given  the  patient  with  very  slight  risk.  But  it  is  other- 
wise where  the  sac  is  very  large,  or  the  contents  adherent,  especially 
about  the  neck  of  the  sac.  In  either  case  the  risk  of  the  operation 
is  increased,  in  the  one  case  from  the  direct  opening  into  the  peri- 
tonseal  cavity  which  may  be  present,  the  large  amount  of  contents 
which  have  to  be  manipulated,  and  the  difficulty  of  keeping  the  operation 
extra-peritonasal.  Again,  intricate  adhesions  about  the  neck  of  the  sac 
may  either  lead  the  surgeon  to  abandon  the  operation,  or  to  lay  open  the 
abdominal  wall  in  order  to  deal  \\'ith  them.  This  last  step  not  only 
increases  the  risk  of  peritonitis  at  the  time,  but  may  bring  about,  some 
time  later,  a  hernia  very  difficult  of  control,  the  ultimate  improvement  in 
the  patient's  condition  being  thus  of  a  very  limited  nature. 

ii.  Cases  of  strangulated  hernia,  where  the  patient's  condition  admits 
of  the  oi:)eration  being  prolonged. 

iii.  Cases  where  a  hernia  is  not  controlled  by  a  truss,  but  slips  beneath 
it.  Such  cases  would  be  extremely  rare  if  patient  and  surgeon  alike 
showed  sufficient  pains  and  patience  in  securing  a  well-fitting  truss, 

iv.  Cases  of  hernia  with  ectopia  testis  where  the  fitting  of  a  truss  to 
keep  the  hernia  up  and  the  testicle  down  fails.  Castration  should  always 
be  performed  when  the  condition  of  the  testis  is  useless  or  doubtful. 

V.  Cases  where  the  hernia  can  be  controlled  by  a  truss,  but  the  use  of 
this  is  irksome  to  a  patient  of  very  active  life,  where  he  wishes  to  join 
the  army  or  navy,  or  where  he  may,  as  a  colonist,  be  far  removed  froin 
surgical  help. 

vi.  Children  of  poor,  ignorant,  and  incompetent  parents,  with  large 
hernise,  where  jiroper  attention  to  the  use  of  a  truss  cannot  be  secured, 
or  Mhere  the  persevering  use  of  this  has  failed,  and  where  all  such 
causes  as  phimosis,  cough,  &c..  have  been  removed.  It  will  probably  be 
justifiable  to  go  further  than  this,  and  to  operate  for  radical  cure  in  most 
cases  of  hernia?  in  the  children  of  the  poor  in  which  the  hernia  is  still 
large  at  four  to  six  years  of  age.*  By  this  time  the  parts  are  better 
developed  and  more  easily  kept  aseptic.  The  sac  is  more  easily  dealt  with 
now  than  later.  The  presence  of  any  conditions  ^^"hich  call  for  explora- 
tion— viz.,  hydrocele,  adherent  omentum,  the  presence  of  the  appendix 
— will  also  be  indications  for  operation  in  children.  On  this  point, 
operation  for  radical  cure  in  little  children,!  I  will  quote  Mr.  Macready 

*  This  age  is  mentioued  above  as  giving  time  for  sufficient  trials  with  a  truss. 

t  Before  deciding  that  a  well-made  truss  will  not  keep  up  a  difficult  case — e.f/..  a 
double  inguinal  hernia — the  hernia  should  be  completely  reduced  with  the  aid  of  an 
anaesthetic. 


RADICAL  CURE  OF  INGUINAL  HERNIA.  6 1 

{loc.  supra  cit.,  p.  256).  We  may  all  envy  his  special  experience  and 
strive  to  imitate  his  skill.  '•  Uncontrollable  ruptures  in  childi*en  under 
fifteen  are  very  rare  ;  to  me,  indeed,  the}'  are  as  yet  unknown.  I  hope 
it  does  not  imply  any  lack  of  charity  to  say  that  one  can  measure  with 
fair  accuracy  a  suro'eon's  skill  in  the  management  of  trusses  by  the 
number  of  curative  operations  he  performs  on  children." 

vii.  Large  herniee,  even  colossal,  Avhere  tlie  patients,  unfitted  for  work 
of  any  kind,  are  a  burden  to  themselves  and  others,*  and  perhaps  willing 
to  run  great  risks ;  for  it  cannot  be  denied  that  these  are  very  grave  cases : 
"  The  operation  usually  difficult  and  prolonged,  and  the  dangers  to  be 
met  and  overcome  both  numerous  and  various  "'  (Banks).  The  chief  of 
these  is  the  direct  and  gaping  communication  M-ith  the  peritontcal  cavity 
and  the  difficulty  in  keeping  the  operation  extra-peritonaeal.  The  best 
proof  of  this  is  given  by  Sir  W.  M.  Banks'  sei'ies  of  sixteen  very  large 
and  enormous  herniaB :  of  these  he  lost  four,  two  from  septicaemia.  In 
another,  even  his  hands  failed  to  complete  the  operation. 

viii.  I  consider  ten  to  twenty-five  years  of  age  the  most  favourable 
time,  as  combining  parts  easy  to  handle,  the  possibility  of  keeping  the 
wound  aseptic,  probable  absence  of  any  difficult  adiiesions,  and  good 
vitality  and  health. 

Choice  of  Operation. — The  following  have  been  brought  pro- 
minently before  the  pi'ofession,  viz.: 
i.  Operation  by  Open  Method. 

ii.  Subcutaneous  Methods — e.ti..  Prof.  Wood's  and  Mr.  Spanton's. 

iii.  Injection  of  Astringents — e.i/..  Oak-bark. 

Of  these,  only  the  operation  by  open  method  will  be  described,  as  it  is 
the  one  of  all  others  which  is  generally  chosen,  owing  to  the  excellent 
results  which  it  has  given,  the  precision  with  which  the  structures 
concerned  can  be  avoided  or  manipulated,  and  its  safety  when  aseptic 
precautions  are  strictly  oliserved. 

i.  The  Operation  by  Open  Method,  t — The  patient  having  been  kept 
in  bed  for  some  time  before,  according  to  the  size  of  the  hernia,  and  any 
cough  attended  to,  only  liquid  diet  is  given  for  the  few  days  preceding 
the  operation,  and  the  bowels  are  duly  emptied. 

Before  describing  the  different  methods  mostly  in  vogue,  I  will  allude, 
for  the  sake  of  my  younger  readers,  to  a  few  points  which  are  always  of 
importance,  whichever  method  is  selected. 

The  thigh  being  a  little  flexed,  an  incision  is  made  over  the  inguinal 
canal,  and  extending  an  inch  below  the  external  abdominal  ring. 
This  divides  skin  and  fascire  and  several  branches  of  the  external  pudic 
arteries  ;  these  should  be  secured  with  Spencer  Wells's  forceps,  which 
will  also  open  out  the  wound.  In  j'oung  males,  especially,  where  these 
vessels  are  of  considerable  size,  care  must  be  taken  that  each  point  is 
firmly  closed  either  by  the  forci-pressure  or  catgut  ligature  ;  otherwise 
free  bleeding  may  readily  take  place  in  the  lax  tissues  of  the  groin,  pre- 

*  As  iu  three  cases  given  by  Sir  W.  II.  Banks :  one,  a  labourer,  unfitted  for  work,  had 
become  an  inmate  of  a  workhouse  ;  the  second  was  a  wine  merchant,  who  had  been 
obliged  to  give  up  his  business,  rarely  venturing  out,  and  then  obliged  to  conceal  his 
deformity  under  a  large  overcoat ;  the  third,  a  glass-blower,  reduced  to  perfect  helpless- 
ness, had  to  depend  on  his  wife  for  his  support. 

t  The  following  remarks  apply  to  inguinal  hernia. 


62  OPEEATIONS  OX  THE  ABDOMEN. 

venting  ])i-imaiT  union,  and  perhaps  leading  to  most  troublesome  tension 
and  suppuration.  The  aponeurosis  of  the  external  oblique  and  the 
cremasteric  fascia  having  been  next  divided,  the  site  of  the  cord  is  made 
certain  of,  and  the  sac  most  carefull}^  defined.  This,  if  empty,  is  by  no 
means  always  eas}",  especially  in  young  subjects.  In  defining  the  sac,  care 
should  be  taken  to  work  carefully  and  without  any  needless  disturbance 
of  the  parts,  or  separation  of  the  planes  of  tissue  here  met  with.  So, 
too,  with  the  cord — great  care  must  be  taken  in  the  next  step,  when  the 
sac  and  this  structure  are  separated;  hasty  work  may  lead  to  needless 
haemorrhage  from  ruptured  veins,  injury  to  the  sac,  or  subsequent 
epididymo-orchitis,  and  even  sloughing  of  the  epididymis  with  part  of 
the  testicle.  The  sac  having  been  accuratel}^  defined,  is  opened  so  that 
an  aseptic  finger  may  make  sure  that  it  is  empty ;  otherwise  any  intes- 
tine is  completely  reduced  or  omentum  dealt  with  according  to  the  steps 
given  at  p.  37.  If  the  question  arise,  whether  the  sac  should  always  be 
opened,  I  should  answer  "  Yes."  Even  if  it  appear  empty  below,  it  is 
satisfactory  to  be  assured  by  digital  examination  that  nothing  lies  within 
the  neck  before  this  is  twisted  or  tied  as  high  up  as  possible.  A  case  of 
Busch's  {Klin.  Med.  Woch.,  1882,  No.  31,  p.  473)  shows  the  importance 
of  taking  this  step. 

Operating  on  a  boy  2f  jears  old  for  a  right  inguinal  hernia,  Busch  tied  the  sac  before 
opening  it.  When  it  was  cut  into  below  the  ligature  the  vermiform  appendix  was 
found  included.  This  was  released  and  returned.  Some  time  later  Busch  was  operating 
on  the  left  side,  and  again  found  that  he  had  included  the  appendix  in  his  ligature 
round  the  sac. 

When  the  emptied  sac  is  next  separated  from  the  cord  and  adjacent 
parts,*  care  must  be  taken,  if  the  patient  strain  at  this  time,  that  no 
escape  of  intestine  occur,  an  assistant  maintaining  pressure  over  the  in- 
ternal ring.  The  cord  must  be  treated  with  the  precautions  given  above, 
and  care  must  be  taken  that  the  testicle  is  not  dragged  needlessly  out  of 
its  bed.  The  sac  is  now  treated,  and  the  canal  closed  by  one  of  the 
methods  given  in  detail  below.  The  wound  having  been  thoroughly 
dried  out,  and  some  sterilised  iodoform  dusted  into  its  recesses,  it 
is  closed  with  sutures  of  salmon-gut  or  horsehair,  care  being  taken 
that  no  inversion  of  the  edges  is  present,  and,  of  far  more  importance, 
that  all  haemorrhage  has  been  entirely  stopped,  including  those  points 
from  which  Spencer  Wells's  forceps  have  been  removed.  If  absolute 
dryness  of  the  wound  has  been  secured,  and  the  operation  has  been 
aseptic  throughout,  no  drainage  is  needed.  A  slip  of  green  protective 
out  of  carbolic  acid  lotion  (i  in  20),  and  some  strips  of  iodoform  gauze 
wrung  out  of  the  same,  are  then  placed  next  the  wound,  and  covered 
by  any  of  the  antiseptic  gauzes  or  wools.  It  is  important  to  keep 
the  scrotum  well  up  on  the  pubes,  and  thus  minimise  the  risks  of 
oedema  of  the  scrotum  and  epididymo-orchitis. 

To  the  above  general  remarks  I  have  onl}^  to  add  that  it  is  always 
well,  when  the  radical  cure  is  performed  in  patients  with  long-standing- 
hernia  (with  important  parts  and  the  sac  perhaps  very  adherent),  or  a 
voluminous  one,  for  the  operator  to  obtain  leave  beforehand  to  sacrifice 
the  testicle ;  and  the  same  course  will  be  taken  when  a  retained  testicle 

*  If  much  difficulty  is  met  with  here,  the  surgeon  should  begin  high  up,  as  near  the 
internal  ring  as  possible,  di\'iding  the  external  oblique  aponeurosis. 


RADICAL  CURE   OF  INGUINAL  IIEEXIA.  63 

is  found  to  be  probably  fuiictionless.  If  it  is  AA-orth  wliile  to  fix  this 
again  in  the  scrotum,  this  should  be  done  according  to  the  steps  given 
under  the  heading  of  Orchidopexy. 

Any  child  or  restless  patient  should  be  secured  in  a  long  outside 
splint.  Finally,  if  any  stitch-sinus  appear,  that  part  of  the  wound 
should  be  well  scraped  out  at  once,  and  made  to  heal  from  the  bottom. 

The  different  methods  that  have  been  elaborated  are  very  numerous, 
and  only  those  which  are  chiefly  in  vogue  at  the  present  time  can  be 
described  here  in  full.  Brief  mention  Avill,  however,  be  made  of  some  of 
the  others.  It  will  be  seen,  if  these  various  methods  be  compared  with 
one  another,  that,  whereas  most  of  them  are  alike  in  aiming  at  recon- 
stituting, in  some  degi'ee.  the  original  valvular  condition  of  the  inguinal 
canal,  on  the  other  hand,  they  differ  chiefly  as  regards  the  method  of 
dealing  with  the  hernial  sac. 

Taking  the  latter  point  first,  it  will  be  seen  that  the  various  special 
methods  that  have  been  devised  for  dealing  with  the  sac  aim  chiefly  at 
converting  the  normal  depression,  or  peritonaeal  fossa,  at  the  position  of 
the  internal  abdominal  ring,  into  a  prominence  with  its  convexity 
towards  the  abdominal  cavity.  Even  if  the  operation  does  succeed  in 
attaining  this,  it  must  surely  be  only  temporary,  for,  clearly,  the  sac  wiU 
rapidly  shrink  and  undergo  partial  absorption.  Moreover,  since  there  is 
normally  a  slight  depression  in  this  position,  and  since  only  a  very 
small  proportion  of  all  individuals  suffer  from  inguinal  hernia,  it  is 
clear  that  the  removal  of  the  depression  at  the  site  of  the  internal 
abdominal  ring  is  not  to  be  looked  upon  as  the  most  important  part 
of  an  operation  for  the  radical  cure  of  a  hernia.  This  contention  is 
borne  out  by  the  results  of  operation,  for  in  Bassini's  operation,  which 
is  so  successful  as  to  be  almost  considered  perfect  (vide  p.  56  for  results), 
the  sac  is  simplv  ligatured  at  its  neck,  and  the  rest  removed,  leaving, 
therefore,  a  depression  in  the  peritonseum  opposite  the  ligature.  With 
regard  to  the  question  of  the  inguinal  canal,  it  is  clear  that  the  normal 
valvular  arrangement  (ru/g  Fig.  12)  of  the  canal  is  extremely  satisfactory 
in  preventing  the  descent  of  an  inguinal  hernia,  since  such  a  very  small 
proportion  of  all  individuals  sufier  from  this  condition.  This  would 
lead  one  to  expect  that  that  operation  which  most  satisfactorily  and 
simply  reconstitutes  the  original  condition  of  the  inguinal  canal  will 
be  attended  with  the  most  satisfactorv  results.  Bassini's  operation 
practicallv  does  reconstitute  the  normal  ingiiinal  canal,  and  moreover 
justifies  the  above  argument,  since  the  results  are  so  satisfactory  and  its 
adoption  is  so  ^^'idespread.  Other  advantages  of  Bassini's  method  are, 
that  it  is  easy  and  straightforward  to  perform,  and  that  the  whole 
length  of  the  canal  is  exposed  to  view,  thus  allowing  (as  pointed  out  b)'- 
Lockwood)  the  removal  of  any  conditions  which  may  be  liable  to  dis- 
tend the  inguinal  canal,  such  as  lipomata  of  the  cord  or  inguinal  vari- 
coceles.     For  these  reasons  Bassini's  operation  will  be  described  first. 

(l.)  Bassinis  Method  (Fig.  14). — An  oblique  incision,  at  least  four 
inches  long  in  an  adult,  somewhat  less  in  a  child,  is  made  over  the 
position  of  the  inguinal  canal,  and  ending  below  opposite  the  pubic 
crest.  The  fascia  having  been  divided,  the  external  oblique  aponeurosis 
is  exposed  and  the  external  abdominal  ring  identified.  The  external 
oblique  is  now  divided  along  the  length  of  the  canal,  and  flaps 
separated   in   both    directions    for   a    short    distance,   thus    thoroughly 


64 


OPERATIONS  OX  THE  ABDOMEN. 


exposing  the  whole  length  of  the  ingumal  canal.  The  sac  is  now 
identified  and  cat-efully  separated  from  the  cord  well  np  to  the  level 
of  the  internal  ring.  It  is  then  opened  and  carefully  emptied,  all 
adhesions  being  carefully  separated,  and  omentum  either  ligatured  and 
removed  or  reduced.  The  neck  of  the  sac  having  been  somewhat  pulled 
down,  is  transfixed  and  ligatui'ed  ^^'ith  silk  or  kangaroo-tendon  at  the 
highest  jDOssible  point,  then  divided  about  half  an  inch  below"  the 
ligature,  and  the  rest  of  the  sac  removed.  Next,  the  cord  is  raised 
carefully  from  its  bed,  and,  supported  in  a  loop  of  gauze,  is  held  forward 
by  an  assistant  while  the  sutures  are  introduced.  At  this  stage  any 
lipomata  of  the  cord  or  an  inguinal  varicocele  may  be  i-emoved,  as 
advised  by  Lockwood.  The  posterior  wall  of  the  inguinal  canal  is  now 
repaired  by  means  of  sutures.  These  will  vary  in  number  from  two  to 
five,  according  to  the  size  of  the  gap  between  the  internal  oblique  or 
conjoined  tendon  on  the  one  hand,  and  Poupart's  ligament  on  the 
other  (i-ide  Fig.  13).     These  sutures  consist  either  of  kangaroo-tendon 


Fig.  12. 


Fig.  13. 


A  normal  inguinal  canal.  Arciform 
fibres  compressing  the  cord  against  Pou- 
part's ligament.     (Lockwood.) 


Inguinal  canal  in  case  of  liernia.  The 
arciform  fibres  are  displaced  upwards,  the 
normal  valvular  condition  of  the  canal 
being  thereby  destroyed.     (Lockwood.) 


or  silk,  and  are  passed  in  the  following  manner: — The  needle  is  first 
passed  through  the  deep  aspect  of  I'oupart's  ligament,  then  beneath 
the  uplifted  cord,  and  finally  through  the  lower  margin  of  the  internal 
oblique  or  conjoined  tendon.  In  order  to  avoid  wounding  the  perito- 
naeum, the  needle  is  passed  through  the  conjoined  tendon  from  its  deep 
to  its  superficial  aspect  {cide  Fig.  14).  Sufficient  suture's  having  been 
passed,  they  are  tied  carefully  and  cut  short,  and  the  cord  allowed  to 
fall  back  into  its  place.  The  divided  edges  of  the  external  oblique 
are  now  united  by  means  of  a  fine  continuous  suture,  and  the 
external  ring,  if  large,  partially  closed  at  the  same  time.  All  bleeding 
having  been  carefully  arrested,  the  skin  is  sutured  and  the  dressings 
applied. 

(2.)  Maceiven's  Operation"'''  (Figs.  15  to  21). 

The  object  of  this  is  tw^ofold:  (i)  So  thoroughly  to  separate  the  sac 


*  Ann.  of  Surg.,  Aug.  1886;  lirit.  Med.  Journ.,  Dec.  10,  18S7. 


HADICAL  CURE  OF  INGUINAL  HERNIA. 


65 


fls  to  allow  of  its  being  completely  reduced  into  the  abdominal  cavity, 
there  to  rest  on  the  inner  surface  of  the  ring,  and  acting  as  a  bulwark- 
like  pad  to  "shed  the  intestinal  waves  away"  from  it.  Prof.  Macewen 
thinks  that  if  the  sac  be  merelj*  tied,  however  carefully  and  high  up  this 
is  done,  there  remains  a  fun- 


nel shaped  puckering,  the 
apex  of  which  presents  in  the 
internal  ring,  and  that  this 
])0uch  gradually  becomes  a 
wedge,  tending  to  open  up 
the  canal. 

Thorough  separation  of  the 
■sac,  and  carrying  this  well 
within  the  peritoneal  cavity, 
is  absolutely  needful,  for  if 
the  sac  be  left  in  the  canal  it 

Fig.  14. 


Fig.  15. 


Bassiui's  operation.  Showing  the 
method  of  inserting  the  deep  sutures. 
(Lockwood.) 


Maceweu's  operation.  The  index  finger,  in- 
serted along  the  inguinal  canal,  is  separating 
the  peritonteum  from  the  internal  aspect  of  the 
internal  ring.  The  folded  sac  is  behind.  In 
this  and  the  following  figures  a  flap  of  skin 
and  cellular  tissue  has  been  reflected,  and  the 
external  oblique  opened  up  so  as  to  expose  the 
canal  and  internal  ring. 


will  act  as  a  plug,  keeping  it  open.  (2)  Again,  to  close  the  dilated 
•canal  and  restore  its  natural  valve-like  condition  by  a  particular  mode 
of  insei'ting  sutures  which  bring  the  conjoined  tendon  in  close  apposi- 
tion with  Poupart"s  ligament,  beginning  with  that  part  of  the  ligament 
\\hich  is  on  a  level  with  the  lowest  part  of  the  internal  ring. 

The  first  object  is  thus  ensured : — The  external  ring  having  been 
•exposed,  the  internal  ring  and  site  of  the  deep  epigastric  are  examined, 
and  the  sac  next  freed  and  raised.  When  this  has  been  done  it  is  kept 
pulled  down  while  the  index-finger  separates  the  sac  from  the  cord,  the 
canal,  and  finally  for  half  an  inch  around  the  abdominal  aspect  of  the 
internal  ring*  (Fig.  15).  The  sac  is  now  folded  on  itself  (Figs.  16,  17) 
by  means  of  a  stitch  which  is  firmly  fixed  in  the  distal  end  of  the  sac. 
The  free  end,  threaded  on  a  hernia-needle  (Fig.  17),  is  introduced 
through  the  canal  to  the  abdominal  aspect  of  the  fascia  transversalis, 
and  there  penetrates  the   abdominal  wall   about   an   inch  above  the 

*  The  object  of  this  is  to  refresh  the  abdominal  aspect  of  the  internal  ring  so  that 
Adhesions  may  form  between  it  and  the  pad  of  sac. 

VOL.  11.  5 


66 


OPERATIO^'y  ox  THE  ABDOMEN. 


internal  ring  (Fig.  i6).  The  wound  in  the  skin  is  pulled  upwards,* 
so  as  to  allow  the  point  of  the  needle  to  project  through  the  muscles 
without  penetrating  the  skin.  The  needle  being  withdrawn  and  un- 
threaded, by  traction  on  the  thread  the  folded  sac  is  drawn  still 
further  backwards  and  upwards.  Traction  having  been  kept  up  on 
the  thread  while  the  sutures  closing  the  canal  are  introduced,  it  is 
finally  secured  by  passing  it  several  times  thi'ough  the  external  oblique 
muscle. 

The  second  part  of  the  operation,  closure  of  the  inguinal  canal,  is 

now  undertaken.     The  fin- 
^^°-  1 6-  ger,  passed  into  the   canal 

and  lying  between  the  in- 
ner and  lower  border  of  the 
internal  ring  in  front  of 
and  above  the  cord,  makes 
out  the  position  of  the  deep 
epigastric  artery  so  as  to 
avoid  it. 

The  hernia-needle,  carry- 
ing chromic  gut,  then, 
guided  by  the  index,  is 
made  to  penetrate  the 
conjoined  tendon  in  two 
places :  first,  from  without 
inwards  near  the  lower 
border  of  the  conjoined 
tendon;  and  secondh',  from 
within  outwards,  as  high 
up  as  possible  in  the  inner 
aspect  of  the  canal :  this 
double  penetration  of  the 
conjoined  tendon  being' 
accomplished  by  a  single 
screw-like  turn  of  the  in- 
strument (Fig.  1 8).  One* 
end  of  the  suture  is  then 
withdrawn,  and  the  needle, 
with  the  other  end,  is  re- 
moved. Thus,  a  loop  is  left 
on  the  abdominal  aspect  of  the  conjoined  tendon,  which  is  penetrated 
twice  (Fig.   19). 

Secondly,  the  other  hernia-needle,  threaded  with  that  part  of  the 
suture  which  comes  from  the  lower  part  of  the  conjoined  tendon,  guided 
by  the  index  in  the  inguinal  canal,  is  passed  from  within  outwards 


Maceweii's  operation.  The  hernia-needle  is 
carrying  the  suture,  threaded  through  the  sac, 
througli  the  abdominal  muscles,  from  behind  for- 
ward, about  an  iuch  above  tlie   internal  ring. 


*  Beginners  will  find  it  best  to  divide  the  aponeurosis  of  the  external  oblique,  and  so 
obtain  sufficient  room  for  rightly  dealing  with  the  sac.  This  requires  an  additional  row 
of  sutures,  and  may  weaken  the  abdominal  wall.  On  the  other  hand,  beginners  will 
always  find  it  difficult,  however  much  the  upper  angle  of  the  wound  is  pulled  iip,  to  get 
the  sac  detached  really  high  up,  and  to  put  the  needful  sutures  into  the  conjoined 
tendon  with  the  limited  incision  which  is  sufficient  for  the  experienced  hands  of  Prof.. 
Macowen. 


RADICAL   CURE   OF  IXGUINAL   HERNIA. 


67 


through  Poupart's  ligament,  which  it  penetrates  at  a  point  on  a  level 
with  the  lower  suture  in  the  conjoined  tendon  (Fig.  20).  The  needle 
is  then  completely  freed  from  the  sutiire  and  withdrawn. 

Thirdly,  the  needle,  now  threaded  with  that  part  of  the  catgiit  which 
protrudes  from  the  upper  border  of  the  conjoined  tendon,  is  passed  from 
within  outwards  through  the  transversalis  and  internal  oblique  muscles 
and  the  aponeurosis  of  the  external  oblique  at  a  point  on  a  level  with 
the  upper  stitch  in  the  conjoined  tendon.  It  is  then  quite  freed  from 
the  suture  and  withdrawn.  There  are  now  two  free  ends  in  the  outer 
surface  on  the  external  oblique,  continuous  with  the  loop  on  the 
abdominal  surface  of  the  conjoined  tendon  (Fig.  21).  The  two  free 
ends  being  drawn  together  tightlv,  and  tied  as  a  reef-knot,  the  internal 


Fig.  18. 


Fig.  17. 


On  the  left  is  one  of  Prof. 
Macewen's  needles.*  Thej' are 
made  of  one  piece  of  steel. 
To  the  right  is  the  sac,  trans- 
fixed and  thrown  into  a  series 
of  folds  bj'  a  thread  which 
should  be  shown  emerging 
above  as  well  as  below. 


Macewen's  operation.  A  hernia-needle  (loaded^ 
has  been  made  to  penetrate  the  conjoined  tendon 
in  two  places. 


ring  is  firmly  closed.  The  same  stitch  may  be  repeated  lower  down  in 
the  canal,  especially  in  adults,  with  wide  gaps.  The  pillars  of  the 
external  ring  may  likewise  be  brought  together.  In  the  gieat  majority 
of  cases  the  first  or  uppermost  stitch  is  all  that  is  re((uired.  The  cord 
should  lie  behind  and  below  the  sutures  and  be  freely  movable  in  the 
canal.  It  is  advisable  to  introduce  all  the  sutures  before  tightening 
any  of  them.  They  may  then  be  experimentally  drawn  tight  while  a 
finger  is  introduced  into  the  canal  to  learn  the  result.  During  the 
operation  the  skin  is  drawn  from  side  to  side  to  bring  the  parts  into 


*  These  are  two  in  number,  one  for  passing  the  thread  from  right  to  left,  and  the 
other  from  left  to  right.  I  have  found  Mr.  AVatsou  Cheyue's  modification  of  the  above 
neeiUes,  in  which  the  instrument  is  angular  instead  of  curved,  much  more  convcnicn:. 
for  picking  up  the  conjoined  tendon  and  external  oblique. 


58 


OPERATIONS  OX  THE  ABDOMEN. 


Fig.  19. 


view.     The  skin  falling  into  position,  the   wound  is   opposite  to  the 
external  ring,  the  operation  being  partly  subcutaneous. 

In  congenital  hernia  the  sac  is  first  separated  from  its  connection 
with  the  canal.  It  is  then  opened,  and  divided  transversely'  into  two 
parts,  care  being  taken  to  preserve  the  cord.  The  lower  part  forms 
a  tunica  vaginalis.  The  upper  is  pulled  down  as  far  as  possible,  split 
behind  longitudinally,  so  as  to  allow  the  cord  to  escape,  and  its 
lower  end  closed  by  a  stitch  or  two.  It  is  then  dealt  with  quite  as 
the  sac  of  an  acquired  hernia. 

The  following  points  deserve  attention. 

The  method  has  been  objected  to  as  complicated  and  difficult,  and 
as  inapplicable  to  infants  on  account  of  the  dithculty  of  making  out  any 

conjoined  tendon  at  this  age. 
The  above  objections  will  dis- 
appear with  practice.  As  Prof. 
Macewen  has  stated,  a  skilled 
finger  will  detect  the  conjoined 
tendon  even  in  early  life. 
Smaller  needles  must,  of 
course,  now  be  used.  Other 
difficulties  are  met  with  in 
this  method  when  the  sac  is 
unusualh'  coarse  and  thick, 
or  when  it  is  extremely  thin  ; 
such  sacs  are,  no  doubt,  diffi- 
cult to  manipulate  satisfac- 
torily, so  as  to  get  the  pad 
well  within  the  internal  ring. 

Professor  Macewen  kindl}^ 
forwarded  to  me  the  following 
statement  (July  1 895)  as  to  his 
results : 

"  I  have  had  164  completed 
cases  of  operation  for  oblique 
inguinal  hernia.  Regarding 
radical  cures,  one  must  neces- 
sarily be  guarded  in  drawing 
conclusions  w^hen  dealing  with 
large  numbers,  as  many  of  the 
patients  pass  from  observa- 
tion, and,  though  asked  to  report  themselves,  do  so  only  a  few  times, 
and  then  cease.  Thus  out  of  164  there  are  55  who  have  dropped 
entirely  out  of  view.  Many  of  these  had  previously  been  seen  three 
to  nine  months  after  operation,  when  they  had  firm  occlusion  of  the 
abdominal  wall.  Two  children  died  after  the  operation — one  from 
scarlet  fever,  epidemic  at  the  time,  and  one  from  measles  and 
meningitis,  the  latter  rather  a  weak  child.  This  leaves  107;  of 
these,  five  are  known  to  have  had  return.  Two  of  these  M^ere  steel 
workers,  doing  the  heaviest  kind  of  work.  One  was  cured  during  eight 
years,  and  then  a  slight  bulge  appeared  near  the  seat  of  the  former 
hernia.  He  now  has  a  bubonocele.  The  other  was  two  years  free  from 
hernia,  and  then  had  a  slight  rupture.     Each  of  those  wear  belts — 


Macewen's  operation.    A  loop  has  been  left  ou 
the  inner  surface  of  the  conjoined  tendon. 


PtADICAL  CURE  OF  INGUINAL  HEIIXIA. 


69 


light  ones,  which  retain  the  hernia  even  during  their  work.  A  third 
remained  well  for  two  years,  then  had  an  attack  of  what  was  stated  to 
be  enteric  fever,  and  sulDsequently  became  affected  with  tubercle  of  the 
lungs.  He  had  a  distinct  recurrence  of  the  hernia.  A  fourth  I  have 
heard  of  as  having  a  return  to  a  slight  extent,  and  a  fifth  wrote  to  say 
that  he  had  a  return. 


Fig.  21. 


Macewen's  operation.  The  thread  from 
the  lower  part  of  the  coujoined  tendon  has 
been  carried  through  Poupart's  hgament. 


Macewen's  operation.  Two  of  the 
threads  which  are  to  draw  the  conjoined 
tendon  over  to  Poiipart's  Hgameut  are  in 
position  ready  for  tying. 


"  If  we  strike  off  nine  cures  under  two  years,  which  are  well,  but 
which  are  too  recent  to  be  judged  as  cures,  this  leaves — 

20  reported  or  seen  cured — no  truss — at  10  years  and  over. 
18         „  „  „  „     6     „ 

29  5'  "  "  ;>       4       '5  >» 

■^  5         "  "  "  >  J     2     , ,  , , 


93 

Some  of  the  older  ones  have  been  good  enough  to  keep  me  well 
informed  as  to  their  state.  Two  have  gone  through  a  great  deal  of  hard 
riding  in  Cape,  for  many  months  at  a  time,  and  have  never  been 
bothered  with  their  old  enemy.  One,  a  surgeon  in  the  Cumberland 
district,  rides  a  great  deal  and  never  is  troubled.  He  says  he  has 
forgotten  that  he  ever  had  a  hernia." 


70  OPERATIONS  ON  THE  ABDOMEN. 

Although  in  Prof.  Macewen's  hands  this  method  has  been  attended 
with  good  results,  A\'hen  performed  Ijy  other  surgeons  the  results  have 
not  been  so  satisfactory.  It  is  clearly  a  more  difficult  and  complicated 
pi'ocedure  than  Bassini's,  and  moreover  the  results  of  Bassini's  method 
are  better  (vide  supra,  p.  56).  Probably  it  is  for  these  reasons  that 
Bassini's  method  is  preferred  by  the  majority  of  operators. 

(3.)  BaWs  Method  {Brit.  Med.  Journ.,  Dec.  10,  1887). — Here  the  sac 
is  twisted,  the  fundus  cut  away,  and  the  stump  stitched  in  the  ring. 
I  have  placed  this  method  next  because  I  consider  the  method  of 
treating  the  sac  by  torsion  much  simpler  than  any  other,  and  very 
efficient.  I  always  treat  the  sac  thus  myself,  though  instead  of  leaving 
it  in  the  canal  I  return  it  within  the  internal  abdominal  ring  after 
Macewen's  method,  and  I  also  make  use  of  Macewen's  method  for 
closing  the  canal. 

Mr.  Ball  advises  that  the  sac  be  completely  isolated  right  up  to  th^ 
internal  ring,  and  having  been  ascertained  to  be  empty,  gradually  twisted 
up  by  a  broad  catch-forceps  grasping  its  neck,  while  the  left  forefinger 
frees  the  upper  part  of  the  neck.*  In  ordinary  cases,  four  to  five  com- 
l)lete  revolutions  are  sufficient,  but  this  must  depend  on  the  thickness 
of  the  sac.  the  torsion  being  continued  till  it  is  felt  to  be  quite  tight 
and  likel}'  to  rupture.  An  assistant  now,  holding  the  torsion-forceps, 
maintains  the  twist  while  a  stout  catgut  ligature  is  tied  tightly 
round  the  twisted  neck  and  cut  short.  Two  sutures  of  stout  aseptic  silk 
are  now  passed  through  the  skin  about  half  an  inch  from  the  edge  of  the 
wound,  through  the  outer  pillar  of  the  ring,  through  the  twisted  sac  in 
iVont  of  the  catgut  suture,  and  then  through  the  inner  pillar  and  skin. 
As  the  sac  now  cannot  untwist,  it  is  cut  off  in  front  of  these  sutures, 
Avhich  are  tied  over  leaden  plates  that  lie  at  right  angles  to  the 
wound.  From  investigations  on  the  dead  body,  Mr.  Ball  finds  that  the 
result  of  the  above  procedure  is  to  throw  the  peritonaeum  into  a  number 
of  special  folds,  radiating  from  the  internal  ring  in  all  directions.  The 
ring,  instead  of  being  depressed,  is  rendered  more  prominent  than  the 
neighbouring  peritonaeum . 

I  have  used  this  most  simple  and  efficient  method  very  largely,  but 
with  some  modifications  of  the  au^thor's  plan.  Thus,  before  twisting  the 
sac  and  after  freeing  it  below  and  from  the  cord,  I  endeavour  to  separate 
it  all  around  the  abdominal  aspect  of  the  internal  ring.  After  twisting 
it  up  as  high  and  as  tightly  as  possible,  I  alwa^ys,  if  it  be  thick  enough, 
transfix  it  instead  of  merely  encircling  it  with  a  gut  ligature.  It  is  then 
pushed  ^^'ell  within  the  peritonaeal  cavity,  as  I  should  fear  leaving  it  in 
the  canal  lest  it  act  as  a  wedge  and  dilate  it.  Finally,  I  al\va3'S  supple- 
ment torsion  of  the  sac  by  closing  the  canal  with  sutures  introduced  by 
Macewen's  method. 

Torsion  is  verj^  quickly  and  simph'  done  ;  moreover,  it  does  away  with 
the  need  of  bringing  a  thread  through  the  abdominal  wall.  Another 
advantage  is  the  crushing  together  of  serous  surfaces,  which  tends  by 
plastic  effusion  to  make  a  plug  ver3^  efficient  in  blocking  the  internal 
ring,  aided  b}"  the  slight  effusion  which  is  set  up  by  the  separation  of 
the  sac  around  the  abdominal  aspect  of  this  aperture. 

*  Where  the  hernia  is  congenital,  the  sac  must  be  cut  through  lirst  above  the  testicle, 
freed  from  the  cord,  and  then  twisted. 


RADICAL  CUliE  OF  INGUINAL  HERNIA.  7 1 

(4.)  Method  of  Banks.* — This  has  the  merit  of  extreme  simplicity. 
The  sac  having  been  made  certain  of,  is  separated,  with  the  precautions 
given  above  (p.  62),  from  the  cord,  and  detached  through  the  external 
ring  up  in  the  canal  as  high  as  the  internal  ring,  the  finger  keeping  note 
all  the  time  of  the  position  of  the  cord.  If  the  sac  is  clearly  empty,  its 
neck  is  now  ligatured  with  stout  chromic  gut  or  carbolised  silk  as  high 
up  as  to  leave  no  neck,  orifice,  or  dimple  at  the  internal  ring.  The 
fundus  is  then  cut  away  about  half  an  inch  below  the  ligature.  As  to 
sutures  of  the  ring  and  canals,  it  would  appear  from  his  latest  paper 
that  the  author  is  now  satisfied  with  suturing  the  external  ring.  •'  In 
inguinal  hernife,  in  addition  to  this  "  (dissecting  out  and  removing  the 
sa(3  as  high  up  as  possible),  '"  the  pillars  of  the  external  ring  have  been 
pulled  together  by  two  or  three  silver  wire  sutures,  which  are  left  in 
position  after  their  ends  have  been  cut  very  short.  They  thus  constitute 
three  small  silver  rings,  which  never  appear  again,  and  are  less  irritating 
than  any  other  form  of  suture.  I  do  not  put  them  in  ^^•ith  any  object 
of  securing  a  permanent  closure  of  the  external  ring,  but  simply  to  make 
sure  that  the  hernia  shall  not  descend  for  a  considerable  period,  so  that 
the  inguinal  canal  (if  it  be  in  fairly  normal  case)  may  have  a  chance  of 
contracting.  Unless  some  extensive  '  rawing '  of  the  walls  of  the  canal 
is  done,  I  believe  all  stitching  of  it  to  be  of  just  as  much  use  in  securing 
permanent  union  as  stitching  the  edges  of  a  cleft  palate  would  be  without 
freely  refreshing  them.  I  do  not  believe  it  possible  satisfactorily  to 
accomplish  a. 'rawing'  of  the  inguinal  canal,  while  in  a  very  large 
proportion  of  severe  cases  there  is  no  inguinal  canal  at  all ;  nothing  but 
a  big  hole  into  which  three  or  four  fingers  can  be  crammed,  whose 
edges  are  as  thin  as  cardboard,  and  from  which  all  anatomical  relations 
have  disappeared.  My  reason  for  adhering  to  the  operation  which  I 
have  hitherto  used  is  that  it  is  the  simplest  of  any  that  has  yet  been 
devised." 

While  all  will  agree  as  to  the  simplicity  of  the  above  method,  there  is 
an  increasing  belief  that  ligature  of  the  sac  alone  is  not  to  be  trusted — 
parti}'-  because  a  sac  thus  treated  is  not  strong  enough  to  resist  future 
strains ;  partly  because,  as  pointed  out  above  by  Prof.  Macewen,  it  is 
extremely  difficult,  if  not  impossible,  to  tie  the  sac  so  high  up  that  no 
dimple  is  left  on  the  peritonteai  aspect  of  the  internal  ring. 

To  take  another  very  important  point.  Sir  W.  Banks  seems  to  have 
given  up  attempting  to  draw  the  canal  together  with  sutures,  because 
these  will  not  ensure  adhesiou  of  the  walls.  But  surely  there  is  a  fallacy 
in  his  comparison.  What  we  want  here  is  not  the  adhesion  of  the  two 
walls  of  the  canal  as  in  the  halves  of  the  soft  palate,  but  a  permanent 
narrowing  of  the  canal  again  so  that  it  may  be  once  more  a  mere  chink 
or  valve  instead  of  a  short  wide  tunnel,  or.  as  in  severer  cases,  a  gaping 
ring.  Even  if  it  were  possible,  adhesion  of  the  walls  of  the  canal  would 
be  undesirable  for  the  sake  of  the  cord. 

With  regard  to  suturing  the  external  ring  alone,  this  is,  I  fear,  from 
cases  I  have  seen,  quite  inadequate.  Some  attempt  should  always  be 
made   to    narrow   the  internal   ring  and   canal,  as   by  the  method  of 


*  Papers  bj'  the  above  surgeon,  one  of  our  earliest  and  foremost  workers  at  the  subject 
will  be  found  in  the  Med.  Times  aiifl  iiaz.,  1884;  Brit.  Med.  Journ.,  Dec.  10,  1887,  and 
Nov.  II,  1893, 


72 


OPERATIOXS  OX  THE  ABDOMEX. 


Bassini.  Final!}',  most  surgeons  have  been  less  fortunate  than  Sir  W. 
Banks  in  their  experience  of  silver  wire.  It  is  verv  readily  sterilised, 
most  easily  used,  but  often  fails  to  become  encysted. 

(5.)  Barker's  Method*  (Fig.  22). — Here  the  upper  part  of  the  sac  is 
drawn  up  into  the  abdomen  and  fixed  there,  but  the  lower  part  is 
always  left  in  sihi,  as  Mr.  Barker  thinks  its  removal  unnecessary  and 
even  mischievous,  "  as  during  the  dissection  the  nervous  and  vascular 
supply  may  be  seriously  damaged."     The  rings  are  then  sutured. 

The  neck  and  upper  part  of  the  sac  having  been  separated  from 
adjacent  parts,  and  proved  to  be  empty,  two  ligatures  of  strong,  fine 
carbolised  silk  are  carried  under  the  neck  and  tied  about  half  an  inch 

Fig.  22. 


Barker's  method,  i,  i,  Skin  incision,  c,  Spermatic  cord,  s,  Lower  part  of  sac 
left  in  situ,  ss,  Sutures  to  invaginate  the  tipper  part  of  tlie  sac.  s.jj,  Sutures  for 
drawing  the  walls  of  the  canal  together. 

apart,  and  the  sac  divided  between  them.  The  upper  ligatures  are  left 
long.  The  left  forefinger,  introduced  into  the  canal  and  through  the 
internal  ring,  is  made  to  press  its  anterior  wall  forwards.  One  of  the 
silk  threads  left  long  on  the  upper  stump  of  the  sac  is  now  threaded  on  a 
needle  with  a  handle,  and  carried  up  the  canal,  inside  the  internal  ring, 
and  through  the  abdominal  wall  above  and  external  to  the  external 
ring.  The  other  is  similarly'  passed  through  the  abdominal  wall  about 
half  an  inch  to  the  inner  side  of  the  first.  These  sutures  are  then 
knotted  tightly,  and  by  this  means  the  stump  of  the  sac  is  drawn  up 
into  the  abdomen  and  fixed  there.     The  external  ring-  is  then  closed 


*  Jjrif.  Med.  Jnvrn..  Dec.  \i 
Soc,  vol.  Ixxiii.  p.  273. 


J/(7«.  of  Opcr.  Si/rff.,  p.  334,  Fig.  51  ;  Trnyu.  Med.-Cklr. 


EADICAL  CURE  OF  INGUINAL  HERNIA. 


73 


by  sutures  which  should,  if  possible,  take  up   the   conjoined    tendon 
as  well. 

(6.)  Bennett's  MetJtod*  (Fig.  23). — Here  also  the  lower  part  of  the 
sac  is  left  in  situ,  for  reasons  similar  to  those  given  above  ;  the  upper 
j^art  of  the  sac  is  invaginated  through  the  internal  ring,  and  the  canal 
sutured  in  the  usual  way. 

The  sac  is  exposed  and  carefully  isolated  from  its  connections  just 
below  the  external  ring  (the  lower  part  being  left  entirely  undis- 
turbed) ;  it  is  then  opened,  and  the  contents  reduced  into  the 
abdomen,  if  they  have  not  already  returned  spontaneously. 

The    sac    is    now    divided    just 
below  the  external  ring,  the  distal  Fig.  23. 

portion  being  allowed,  after  all 
bleeding  has  been  stopped,  to 
drop  back  into  the  scrotum.  The 
proximal  part  of  the  sac  is  next 
separated  from  the  sides  of  the 
canal  as  high  up  as  the  internal 
ring  by  gentle  manipulation.  One 
finger  (or  more  if  the  ring  is  large) 
of  the  left  hand  havino-  been  intro- 
duced  into  the  abdominal  cavity 
through  the  neck  of  the  sac,  any 
bowel  lying  near  the  internal  ring- 
is  pressed  back  out  of  the  way. 
An  ordinary  pile-needle  on  a  handle 
(unthreaded)  is  then  made  to  enter 
the  abdominal  aponeuroses  about 
three-quarters  of  an  inch  above  the 
upper  margin  of  the  external  ring,  a 
little  to  the  outer  side  of  its  middle 
line,  and  transfixes  the  whole  of 
the  aponeuroses  and  peritonaeum, 
impinging  on  the  end  of  the  finger 
which  occupies  the  neck  of  the  sac. 
The  needle,  guided  by  the  finger,  is 
passed  down  the  inside  of  the  sac 
and  made  to  pierce  its  outer  wail  at 
a  point  about  half  an  inch  from  the 
cut  edge.  The  needle  having  been  threaded  with  a  tendon  or  catgut 
suture,  previously  prepared,  and  not  less  than  twelve  inches  long,  is 
withdrawn,  taking  one  end  of  the  suture  with  it.  The  result  is  that 
one  end  of  the  suture  is  seen  passing  into  the  abdominal  aponeuroses 
above  the  external  ring,  while  the  other  issues  from  the  outer  wall  of  the 
proximal  part  of  the  sac,  near  its  cut  edge.  The  needle,  again  un- 
threaded, is  now  made  to  transfix  the  abdominal  aponeuroses  and  peri- 
toneum about  half  an  inch  internal  to  the  point  at  which  it  entered 
before,  traversing  the  sac  in  the  same  way,  finally  piercing  the  inner 
wall  at  about  the  same  distance  from  the  cut  edge  as  it  had  done  on 
the  outer  side.     After  havino-  been  threaded  with  the  lower  end  of  the 


Bennett's  method.  The  pillars  of  the 
external  ring  are  shown.  Some  distance 
above  them  the  two  invagination  sutures 
are  seen  to  emerge  through  the  aponeu- 
roses, while  below  they  pass  through  the 
sac,  which  has  also  been  tied. 


*  Abdominal  Hernia,  p.  i{ 


74 


OPERATIONS  ON  THE  ABDOMEN. 


suture,  the  needle  is  withdrawn,  carrying  the  suture,  as  before,  with  it. 
The  two  ends  of  the  suture  will  now  be  seen  entering  the  aponeuroses 
above  the  external  ring,  and  forming  below  a  loop  over  the  cut  edge 
of  the  proximal  portion  of  the  sac.  The  open  end  of  the  sac  is  next 
sewn  up  by  a  continuous  stitch  of  catgut  or  silk,  or  occluded  by  a 
silk  ligature  placed  around  it  as  close  as  possible  to  the  spot  at  which 
the  invagination  suture  pierces  its  sides.  The  succeeding  step  is  the 
invagination  of  the  sac,  which  is  effected  by  pushing  wdth  the  finger 
the  closed  end  through  the  canal  into  the  abdomen,  the  invagination 
sutures  passing  through  the  aponeuroses  being  at  the  same  time  drawn 
tight.  By  this  proceeding  the  sac  is  turned  completely  outside-in,  and 
its  fundus  firmly  attached  to  the  peritonaeal  surface  of  the  anterior 
abdominal  wall  some  distance  above  the  internal  ring. 


Fig.  25. 


Fig.  24 


Testis 


Figs.  24,  25,  aud  26  :  Method  of  treating  the  sac  in  Bishop's  method  of  radical 
cure  of  hernia.  In  Fig.  24  the  sac  is  hemmed  round  with  a  silk  suture.  lu  Fig.  25 
the  sac  is  puckered  upon  the  outer  side  of  the  ring.  In  Fig.  26  the  puckered  sac  is 
invaginated  and  forms  a  l)utton-like  projection  on  the  abdominal  aspect  of  the 
ring.    In  each  figure  the  suture  carries  a  needle  at  each  end.     (Walsham.) 

(7.)  Staninore  Bishops  MetJcod*  (Figs.  24,  25,  and  26). — This  is  a 
modification  of  Prof.  Macewen's.  The  sac  having  been  freed  entirely  up 
to  but  not  beyond  the  internal  ring,  is  carefully  emptied,  and  kept  so 
by  the  finger  of  an  assistant  pressing  upon  the  ring.  By  means  of  a 
long,  strong  catgut  suture,  -which  is  passed  through  each  side  of  the 
sac,  this  is  hemmed  round,  aud  thrown  into  a  number  of  folds.  The 
neck  of  the  sac  is  then  invaginated,  and  each  end  of  the  suture  carried 
by  a  needle  through  the  canal  and  through  the  pillar  of  the  internal 


*  Lanret,  vol.  i.  i8go.  p.  1237, 


RADICAL  CUKE  OF  INGUINAL  IIEIiXIA. 


75 


ring  nearest  to  it.  from  within  outwards.  When  both  ends  are  pre- 
senting through  the  muscular  structures  they  are  pulled  up,  the  sac 
being  at  the  same  time  invaginated  before  the  finger  as  the  threads  are 
drawn  upon.  The  sac  is  then  drawn  inside-out  in  its  passage,  and 
becomes  fixed  at  a  rounded  boss  exactly  over  the  inner  ring,  its  peri- 
tongeal  surface  being  turned  to\\-ards  the  intestines,  and  its  first  fold  on 
either  side  being  firmly  applied  to  the  peritonseum  immediately  within 

Fig.  27. 


Halsted's  operation.  The  iuguiual  caual  laid  open ;  the  sac  cut  away  after 
suture  of  the  peritouseum  ;  elements  of  cord  isolated  and  lifted  up ;  deep  (|uilt 
sutures  introduced. 

A,  Aponeurosis  of  the  external  oblique.  D,  Yas  deferens.  F,  Fascia  transversalis. 
P,  Remains  of  sac  sutured.  T,  Conjoined  tendon.  Y,  One  of  the  spermatic  veins. 
VV,  Stumps  of  excised  spermatic  veins. 

the  ring.     The  ends  of  the  suture  are  then  tied  firmly,  but  not  tightly. 
over  the  ring ;  finally,  this  and  the  canal  are  sutured. 

(8.)  Method  of  Halsted* — The  following  is  Prof.  Halsteds  account 
of  his  operation  (Figs.  27  and  28)  :    "  Instead  of  trying  to  repair  the  old 


*  Halsted.     Bulletin  of  the  Johns  Hopkins  Hosp.,  voL  i.  No.  i ;  Johm  Iloj^hins  Hasp. 
Jlep.,  voL  ii. ;  Surg.  Fasciculus,  No.  i ;  Ann.  of  Surg.,  1893,  voL  i.  p.  542. 


16 


OPERATIONS  OX  THE  ABDOMEN. 


canal  and  the  internal  abdominal  ring,  I  make  a  new  canal  and  a  new 
ring.  The  new  ring  should  fit  the  cord  as  snugly  as  possible,  and  the- 
cord  should  be  as  small  as  possible.  The  skin  incision  extends  from  a 
point  about  5  cm.  above  and  external  to  the  internal  ring  to  the  spine 
of  the  pubes.  The  subciitaneoiis  tissues  are  divided,  so  as  to  expose- 
clearly  the  aponeurosis  of  the  external  oblique  and  the  external  ring. 
The  aponeurosis  of  the  external  oblique,  the  internal  oblique  and  trans-^ 
versalis  and  the  transversalis  fascia  are  cut  throuo-h  from  the  external 


Fig.  28. 


Halsted's  operation.  The  deep  quilt  sutures  wbich  cross  tlie  canal  are  tied  and 
cut  short.  The  remains  of  the  cord  are  seen  to  emerge  between  the  upper  two 
sutures,  and  to  lie  between  the  external  oblique  and  the  skin. 


abdominal  ring  to  a  point  about  2  cm.  above  and  external  to  the 
internal  ring.  The  vas  deferens  and  the  blood-vessels  of  the  cord  are- 
isolated.  Ail  hut  one  or  tiro  of  the  veins  of  the  cord  are  excised  (Fig.  27),- 
The  sac  is  carefully  isolated  and  opened,  and  its  contents  replaced.  A- 
piece  of  gauze  is  usually  employed  to  replace  and  retain  the  intestines. 
With  the  division  of  the  muscles  and  transversalis  fascia,  the  so-called 
neck  of  the  sac  vanishes.  There  is  no  longer  a  constriction  of  the  sac. 
The   communication   between   the    sac  and   the    abdominal    cavity    is- 


RADICAL  CURE  OF  IXGUIXAL  HEUNIA.  jy 

sometimes  large  enough  to  admit  one's  hand.  The  sac  having  been 
completely  isolated  and  its  contents  replaced,  the  peritonseal  cavity  is 
closed  by  a  few  fine  silk  mattress  sutures,  sometimes  by  a  continuous 
suture.  The  sac  is  cut  away  close  to  the  sutures.  The  cord  in  its 
reduced  form  is  raised  on  a  hook  out  of  the  wound,  to  facilitate  the 
introduction  of  the  six  or  eight  quilt  sutures,  which  pass  through  the 
aponeurosis  of  the  external  oblique,  and  through  the  internal  oblique 
and  transversalis  m\iscles  and  transversalis  fascia  on  the  one  hand,  and 
through  the  transversalis  fascia  and  Poupart's  ligament  and  fibres  of 
the  aponeurosis  of  the  external  oblique  on  the  other  (Fig.  27).  The 
two  outermost  of  the  deep  quilt  sutures  pass  through  muscular  tissues, 
and  the  same  tissues  on  both  sides  of  the  wound.  The}"  are  the  most 
important  sutures,  for  the  transplanted  cord  passes  out  between  them. 
If  placed  too  close  together,  the  circulation  of  the  cord  might  be  im- 
23erilled,  and  if  too  far  apart  the  hernia  might  recur.  They  should, 
however,  be  near  enough  to  each  other  to  grip  the  cord  (Fig.  28).  The 
precise  point  to  which  the  cord  is  transplanted  depends  upon  the  con- 
dition of  the  muscles  at  the  internal  abdominal  ring.  If  in  this  situation 
thej'  are  thick  and  firm,  and  present  broad  raw  surfaces,  the  cord  may 
be  brought  out  here.  But  if  the  muscles  are  attenuated  at  this  point, 
and  present  their  cut  edges,  the  cord  is  transplanted  further  out.  The 
skin  wound  is  brought  together  by  an  uninterrupted  suture,  which  is 
withdrawn  after  two  or  three  weeks.  The  transplanted  cord  lies  on  the 
aponeurosis  of  the  external  oblique,  and  is  covered  b}'  skin  only." 

There  are  serious  objections  to  this  operation,  and  the  results,  though 
good,  are  not  more  favourable  than  those  of  Bassini's  operation.  The 
first  objection  is  that  the  procedure  is  complicated,  and  more  difficult  to 
perform  than  Bassini's  operation,  and  the  length  of  time  occupied  by 
the  operation  thereby  needlessly  increased.  The  second  and  more 
serious  objection  is  the  efiect  on  the  cord  and  the  testis.  O'Conor 
(Lancet,  Aug.  26,  1899)  says  that  in  80  per  cent,  of  his  cases  treated 
by  Halsted's  method  orchitis  followed,  and  in  20  cases  out  of  129 
atrophy  of  the  testis  resulted.  This  may  be  traced  either  to  the 
superficial  position  of  the  cord,  or  to  the  free  removal  of  spermatic 
veins. 

(9.)  Method  of  Koclier* — This  method  is  worth  noting,  as  it  is 
claimed  that  by  it  the  sac  is  stretched  in  a  direction  opposite  to  that 
of  the  inguinal  canal  and  the  course  of  the  hernia  ;  and  that  when  the 
sac  is  fixed  in  situ,  this  is  done  more  firmly  and  in  a  more  permanent 
manner  than  by  other  methods. 

The  skin  and  superficial  fascia  are  divided  over  the  canal.  At  the 
external  ring  the  inter-columnar  and  cremasteric  fasciae  are  divided,  and 
the  sac  defined.  This  is  then  carefully  isolated  from  adjacent  structures, 
and  strongly  pulled  down  so  that  its  pedicle  may  be  exposed.  The  left 
index  finger  is  now  introduced  into  the  inguinal  canal,  and  to  one  side 
of  the  internal  ring  a  small  opening  is  made  through  the  aponeurosis  of 
the  external  oblique  ;  a  slender  pair  of  artery-forceps  is  passed  through 
this  opening  and  through  the  lower  muscular  fibres  of  the  internal 
oblique  and  transversalis,  following  the  left  index  as  it  is  withdrawn, 
through  the  inguinal  canal,  and  finally  out  of  the  external  inguinal 

*  A?m.  of  Siirrj.,  1892,  vol.  ii.  p.  524. 


78 


OPERATIONS  OX  THE  ABDOMEN. 


opening.     With  these  the  isolated  sac  is  grasped  and  drawn  through 
the   canal,  and   out   at  the   small   opening  in  the  aponeurosis  of  the 


Fig.  29. 


Fig. 


30. 


Koclier's  operation.  The  for- 
ceps, introduced  along  the  inguinal 
canal,  are  grasping  the  sac  at  the 
lower  end. 

external  oblique  (Fig.  30). 
and  energetically  twisted. 


Fig. 


31- 


Koclier's  operation.  The  sac  having  been 
twisted,  is  laid  down  upon  the  aponeurosis  of 
the  external  oblique.  Eight  deep  sutures  are 
also  shown. 


(10.)  McBnrnei/s  Method. 


Koclier's  operation.  The  sac  is  drawu 
out  through  a  small  opening  in  the  external 
oblique  aponeurosis. 

It  is  Ihen  drawn  out  as  much  as  possible. 
It  is  next  strongly  drawn  down  and  laid 
over  the  outer  surface  of  the  ex- 
ternal oblique  and  outer  ring,  in 
the  direction  of  the  canal.  By 
this  tension  of  the  sac  the  anterior 
wall  of  the  unopened  canal  is 
pressed  backwards  into  a  gutter. 
Deep  sutures  are  now  applied, 
being  passed  above  the  twisted 
sac,  through  the  aponeurosis  of 
the  external  oblique  and  the  in- 
ternal oblique  and  transversalis, 
through  the  sac  itself,  and  taking- 
up  Poupart's  ligament  below  (Fig. 
31).  In  the  case  of  a  long  sac, 
all  that  extends  below  the  outer 
ring  is  cut  away. 

It  is  claimed  that  by  this 
method  the  sac  is  firmlj^  drawn  on 
the  stretch,  and  securely  pressed 
over  the  entire  length  of  the 
canal,  so  as  to  form  a  solid  pad 
or  roll.  The  deep  sutures  would 
appear  to  be  passed  somewhat  in 
the  dark,  as  regards  the  cord. 
This  is  different  from  all  others  described, 


RADICAL  CURE  OF  FEMORAL  HERNIA.  79 

in  that,  instead  of  trying  for  primary  nnion,  the  wound  is  made  to  heal 
by  granulation  tissue. 

The  sac  having  Ijeen  reached  by  an  incision  exposing  the  whole  canal 
and  external  ring,  is  separated  and  tied  as  high  up  as  possible.  The 
part  below  the  ligature  is  then  cut  away.  In  order  to  keep  the  wound 
an  open  one,  the  superficial  are  then  stitched  to  the  deep  parts  ;  next, 
skin  and  conjoined  tendon  above,  skin  and  Poupart's  ligament  below, 
are  sutured  together.  The  wound  is  then  packed  with  iodoform  gauze. 
The  wound  is  thus  made  to  fill  up  by  granulation  tissue,  producing 
a  thick  scar,  which  McBurney  believes  to  be  the  best  guard  against 
relapse. 


RADICAL    CURE    OF    FEMORAL    HERNIA. 

There  is  less  necessity  for  operative  interfei'ence  here — women,  in 
whom  the  above  variety  is  so  much  more  frequent,  finding  a  truss  more 
efficient  and  less  irksome,  owing  to  their  less  active  life  and  their  mode 
of  dress.  In  omental  hernia,  Avhere  there  is  difficulty  in  fitting  or  un- 
willingness to  wear  a  truss,  in  irreducible  hernia,  and  in  all  cases  of 
strangulated  hernia,  where  the  patient's  condition  and  the  surroundings 
of  the  operator  admit  of  it,  an  attempt  should  be  made  to  cure  the  hernia 
permanently.  We  are  met  here  by  a  difficulty  less  present  in  inguinal 
hernia — i.e.,  that  of  closing  the  canal  satisfactorily,  owing  to  the  scanti- 
ness of  some  of  its  immediate  surroundings  and  the  importance  of  others. 

Different  methods  : — 

i.  The  empty  sac  having  been  thoroughly  separated  from  its  sur- 
roundings— a  step  here  usually  carried  out  with  ease — is  twisted  up 
tightly,  transfixed,  and  tied  with  reliable  catgut,  and  then  thoroughh' 
invaginated  within  the  femoral  ring. 

ii.  Kocher's  method  (p.  yf)  may  be  emploj^ed.  The  empty  sac 
having  been  isolated  and  twisted  as  strongly  as  possible,  is  drawn 
through  a  small  opening  made  above  Poupart's  ligament,  and.  much  as 
described  at  p.  y8.  included  in  sutures  which  are  passed  through  the 
pectineal  fascia  and  Poupart's  ligament  with  the  hope  of  closing  the 
femoral  canal. 

iii.  The  sac  may  be  treated  much  as  in  the  methods  of  Barker  and 
Bennett  (pp.  72  and  73).  Thus,  after  it  has  been  isolated  and  emptied, 
the  neck  is  thoroughly  cleared  with  the  finger  passed  up  the  femoral 
canal.  The  neck  is  now  ligatured  as  high  up  as  possible,  the  body  of 
the  sac  cut  away,  and  the  ends  of  the  ligature,  which  have  been  left 
long  around  the  neck  of  the  sac,  are  carried  up  the  femoral  canal  by 
means  of  needles  on  handles  alons'  the  index  finoer.  and  made  to  emero'e 
in  front  of  the  peritonaeum  through  the  external  oblique  aponeurosis 
just  above  Poupai't's  ligament,  about  half  an  inch  apart.  When  these 
are  tied  the  sac  will  be  invaginated.  While  the  above  ligatures  are 
being  passed  one  assistant  should  protect  the  femoral  vein,  while 
another  draws  up  the  upper  angle  of  the  skin  incision  so  that  the 
needles  may  emerge  in  the   wovind. 

The  above  refers  chiefly  to  treatment  of  the  sac.  The  other  cardinal 
step  in  the  radical  cure  of  femoral  hernia — closui'e  of  the  femoral  canal 
and  ring — is  niucli  more  difficult  here,  for  reasons  above  given,      Fortu- 


8o 


OPERATIONS  ON  THE  ABDOMEN. 


nately  trusses  are  much  less  of  an  infliction  here,  and  thorough  oblitera- 
tion of  the  sac  on  some  of  the  lines  I  have  described  will,  with  the  aid 
of  a  light-fitting  truss,  suffice  amply.  Where  it  is  desired  to  go  further 
and  close  the  femoral  ring  and  canal,  one  of  the  following  methods  may 
be  made  use  of. 

■  iv.  Lochvood's  Method*  (Figs.  32,  33,  and  34). — The  stump  of  the  sac 
is  first  drawn  up  and  fixed  as  above  described.  The  subsequent  steps 
are  described  by  the  author  as  follows :  "  For  this  purpose  the  index 
finger  of  the  left  hand  is  pushed  up  the  femoral  canal  so  that  it  lies 
with  its  dorsum  against  the  common  femoral  vein,  and  its  tip  upon 
and  a  little  within  the  ilio-pectineal  ridge.     The  finger  is  intended  to 

Fig.  32. 


a,  Poupart's  ligament.  &,  Lacuna  musfularis.  c,  Tiacuna  vascularis.  cZ,  Cooper's 
ligament,  e,  Gimbernat's  ligament,  g,  Ilio-pectineal  ligament,  h,  Ilio-pectineal 
eminence,    s,  Sj)ermatic  cord.     (Lockwood.) 

protect  the  vein  from  the  point  of  the  herniotomy-needle,  and  to  guide 
the  latter  as  its  point  is  thrust  beneath  Cooper's  ligament  (vide  Fig. 
32).  In  cases  in  which  the  femoral  canal  has  been  distended  and 
stretched,  the  needle  can  be  guided  by  vision.  The  herniotomy- 
needle  is  passed  in  the  following  manner : — Having  been  armed  with 
about  one  and  a  half  feet  of  No.  4  or  5  twisted  silk,  its  point  is  guided 
up  the  femoral  canal  until  it  rests  against  the  inside  of  the  linea  ilio- 
pectinea,  opposite  the  outer  edge  of  Gimbernat's  ligament.  The  needle 
is  then  rotated  so  that  its  point  scrapes  over  the  linea  ilio-pectinea  and 


*  Ilernin,  Hydrocele,  and   Varicocele,  p.   192. 


EADIOAL  CURE  OF  FEMORAL  HERNIA. 


picks  up  Cooper's  ligament.  Finally,  the  point  emerges  through  the 
upper  part  of  the  pectineal  fascia,  where  it  is  unthreaded  and  -with- 
drawn, leaving  the  suture  beneath  Cooper's  ligament  (vide  Fig.  33). 
Additional  sutures  are  passed  in  exactly  the  same  way,  but  each  a  little 
farther  outwards  until  the  last  lies  at  the  inner  edge  of  the  common 
femoral  vein.  Two  or  three  sutures  generally  suffice,  but  I  have 
used  as  many  as  five.  The  next  step  is  to  again  thread  the  upper 
end  of  each  ligature  in  turn  through  the  herniotomy-needle,  and,  by 
pushing  the  point  of  the  needle  half-way  up  the  femoral  canal  and 
rotating  it  forwards,  pass  the  thread  from  within  outwards  through 
Hey's  ligament  close  to  its  junction  with  Poupart's  ligament  (yule 
Fio-.  33).  Before  knotting  these  threads  the}'  are  pulled  tight,  to 
see  whether  enough  have  been  passed  to  make  a  thorough  and  firm 
closure   of  the   femoral   canal,  but   without   compressing  the    femoral 

Fig.  33. 


Lockwood's  oi:)eration.     Showing  the  mode  of  suturing  the  femoral  caual. 

vein  (vide  Fig.  34)."  The  final  results  of  Mr.  Lockwood's  cases  are 
not  fully  given,  owing  to  the  difficulty  in  following  them  up.  Ten 
cases,  however,  are  mentioned.  In  nine  of  these  the  result  was  satis- 
factory after  periods  var^-ing  from  one  to  seven  years ;  the  tenth  case 
relapsed  sviddenly  at  the  end  of  six  months. 

V.  Bassini's  Method.  —  After  hioh  lio-ation  and  removal  of  the 
sac,  the  canal  is  closed  in  the  following  manner : — Three  sutures  are 
passed  through  Poupart's  ligament  and  the  pectineal  fascia.  These 
are  left  untied  while  three  or  four  more  sutures  are  inserted  and 
tied.  These  unite  the  falciform  ligament  to  the  pectineal  fascia, 
the  lowest  being  placed  close  to  the  saphenous  vein.  Bassini  has 
published  fifty-four  cases  operated  upon  by  this  method,  without  any 
recurrence  in  fortj'-one  cases,  traced  from  one  to  nine  3*ears. 

VOL.    II.  "^  6 


OPERATIONS  OX  THE  ABDO.MEX. 


RADICAL    CURE    OF    UMBILICAL    HERNIA. 

This  operation  is  rarely  called  for :  in  children  the  natural  tendency 
to  cure  is  very  marked ;  and  in  adults,  the  kind  of  patients  usually  met 
Avith — stout  women  of  middle  age  with  damaged  viscera,  bronchitis,  &c. 
— are  not  suitable  for  operative  interference,  save  after  the  operation 
for  strangulation  (p.  49). 

Treatment  b}^  operation  ma}'  be  considered  under  the  following 
heads : — 

i.  In  Congenital  Hernia  of  the  New-born  Child. — In  these  cases, 
either  herniee  into  the  root  of  the  cord,  or  (from  deficiency  of  the 
abdominal  walls)  partial  eventrations,  interference  is  often  out  of  the 
question  from  the  co-existence  of  other  malformations.  If  the  hernia 
be  uncomplicated,  and  the  child  appear  likely  to  survive  otherwise, 
an  attempt  should  be  made  by  abdominal  section  to  return  the  con- 
tents, refresh  the  edges  of  the  opening,  and  unite  them  with  sutures. 


Fig.  34. 


Lockwood's  operation.     Showing  the  closure  of  the  femoral  eaual  comijleted. 

ii.  In  Infantile  Hernia — the  common  form  in  children. — In  those 
rare  cases,  where  the  wearing  of  a  truss  has  not  been  sufficient,  an 
operation  may  be  performed  with  excellent  prospects  of  success.  A 
simple  method  is  to  explore  the  hernia,  reduce  the  contents,  and 
then,  after  cutting  away  superfluous  sac  and  scar  tissue,  to  unite  the 
different  layers — peritonasum,  fibrous  tissues,  and  skin — by  separate 
layers  of  sutures. 

In  cases  where  a  pedicle  can  be  made  to  the  sac — not  always,  from 
my  experience,  an  easy  matter,  owing  to  the  directness  and  shortness 
of  the  opening — it  may  be  twisted  and  invaginated  as  advised  at  p.  yo, 
and  the  other  structures  sutured  over  it,  or  it  may  be  invaginated  after 


RADICAL  CUEE   OF  UMEILICAL  HEliNIA. 


83 


the  method  of  Barker  (p.  72)  or  Bennett  (p.  73).  Another  method 
is  that  of  Mr.  Keetley  (Ann.  of  Sut<j.,  Sept.  1887).  The  sac  having 
been  separated  and  twisted  as  in  Mr.  Ball's  method  (p.  70),  a  stout 
catgut  suture  is  passed  through  it,  and  the  peritonaeum  being  very 
carefully  separated  from  the  linea  alba  above  the  ring,  a  needle  is 
passed  up  into  the  space  thus  made,  carrying  the  catgut,  threaded, 
through  the  sac,  and  brought  out  through  the  linea  alba.  Then, 
on  pulling  the  catgut  tight,  the  twisted  sac  is  drawn  into  the 
space  between  the  peritonaeum  and  the  linea  alba.  The  edges  of  the 
hernial  aperture,  now  freed, 

are   pared   and  brought    to-  ^"''  "" 

gether  with  pins  and  twisted 
suture. 

For  those  cases  of  adult 
umbilical  hernia  where  the 
age  and  the  condition  of  the 
patient  as  to  her  lungs  and 
other  viscera  are  sufficiently 
I'avourable,  and  where  a 
truss  or  belt  is  found  use- 
less, the  operation  already 
recommended  in  herniotomy 
for  strangulation  (p.  49).  and 
the  steps  for  taking  away 
the  sac  and  redundant  skin 
and  suturing  the  ring,  will 
be  found  sufficient. 

Other  methods  are  those 
of  the  late  Mr.  McC4ill,  of 
Leeds,  who  advocated  (Brit. 
Med.  Journ.,  1890,  vol.  i. 
p.  428)  a  modihcation  of 
Macewen's  method,  i.e..  the 
formation  of  an  internal 
pad  made  from  part  of  the 
sac  and  fixed  in  the  sub- 
peritonaeal  space  over  the 
neck  of  the  sac.  M.  Lucas- 
Championniere.  in  his  work 
on  the  Radical  Cure  of 
Hernia,  advises  that  the 
fibrous  edges  of  the  wound 
be  so  refreshed  and  sutured 
that  the  edge  of  one  side 
shall  overlap  that  of  the 
other. 

The  skin  incision  is  united 
in  the  ordinary  way. 

The  chief  points  to  bear 
in  mind  in  the  radical  cure 
of  umbilical  hernia  are  well 
Mr,  Greig  Smith  (Fig.   35). 


Greig  Smith's  method  of  radical  cure  in  iimbilical 
hernia.  A,  Transverse  section  through  hernia  and 
parietes,  showing  sac,  contents,  and  ring,  ix,  In- 
testine. OM,  Omentum.  sk,  Skin.  f,  Fascia 
thickened  at  margin  of  ring,  m,  Eectus.  p,  Peri- 
toneum. I,  Incision  through  skin  of  sac,  wbicli  is 
continued  along  the  sub-peritonaeal  tissue  to  the 
margin  of  the  ring.  2,  The  same  on  the  opposite 
side.  3  and  4,  Incisions  carried  deeply  through 
thickened  fascia  around  the  ring  to  expose  the  recti. 
B.  Gut  returned,  omentum  removed,  superfluous 
skin  and  sac  removed,  sutures  placed,  incisions  in 
fascia  opened  up  and  recti  exposed.  Eeferenees 
same  as  in  A.  C,  Sutures  tied,  skin-suture  to  one 
side  of  parietal  line  of  junction.  D,  Bird's-eye  view 
showing  double  set  of  sutiires  around  umbilical  ring 
and  cutaneous  ■wound.     (Walsham.) 

shown  in  the  above  drawing  by  the  lata 


84  0PERATI0N6  OX  THE  ABDOMEN. 

Causes  of  Death  and  of  Complications  which  may  be  met  with 
after  Operations  for  the  Badical  Cure  of  Hernia. 

I.  Sepsis.  2.  Peritonitis.  3.  Scarlet  fever.  4.  Tubercular  menin- 
gitis. This  may  occur  in  patients  the  subjects  of  other  apparently 
quiescent  tubercular  trouble — e.^/.,  spinal  caries.  5.  Bronchitis  due 
to  the  ancesthetic ;  a  danger  especiall}'  to  be  avoided  in  a  child  who 
has  lately  had  measles.  6.  Pneumonia.  7.  Pulmonary  embolism. 
8.  Nephritis,  9.  Epididymo-orchitis.  10.  Sloughing  of  epididymis 
and  testicle.  1 1 .  Flatulence,  ^A'ith  troublesome  distension.  This 
condition,  so  well  known  after  operations  on  the  interior  of  the  abdo- 
men, is  known  by  some  as  "pseudo-peritonitis."*  It  is  best  met  by 
aperients — e.g.,  calomel  gr.  v.  and  Seidlitz  powders,  given  alternately 
every  three  hours,  until  the  bowels  act ;  or  the  following  enema  may 
be  useful:  castor  oil  §ij.,  turpentine  §j.,  soap  and  water  to  8  oz.  12.  Re- 
currence. This  may  be  due  to  the  patient's  fault,  i.e.,  his  not  having 
worn  a  truss  when  this  was  obviously  indicated.  More  often  it  is  due 
to  faultj^  oi:)erating,  suppuration,  and  the  resulting  thin,  stretching- 
scar  ;  or  to  stitch-abscesses  and  sinuses,  to  which  I  have  referred  above. 

*  Where  a  large  quantity  of  omentum  has  been  tied  close  by  the  colon,  the  action  of 
the  latter  may  be  inhibited,  and  the  above  complication  follow  to  a  marked  degree. 


CHAPTEE     III. 
COLOTOMY. 

UxDfZR  this  term  are  included  tlie  anterior  iliac  or  ingninal  colotomy  of 
Littre,  in  which  the  sigmoid  colon  is  opened  in  the  left  iliac  region ; 
that  of  opening  the  ascending  or  descending  colon  in  the  loin,  or 
lumbar  colotomy — an  operation  with  which  the  name  of  Amussat*  is 
justly  associated ;  finally,  the  question  of  making  an  artificial  anus  in 
the  caecum  or  transv^erse  colon  is  considered. 

The  question  of  the  value  of  colotomy,  compared  with  excision  of 
the  rectum,  in  cases  of  cancer  is  dealt  with  later  on. 

Before  describing  and  comparing  the  different  modes  of  performing 
colotomy  I  shall  deal  with  those  conditions  which  call  for  this  procedure, 
then  the  advantages  of  the  chief  methods  and  the  cases  to  which  they 
are  relatively  adapted,  describing  finally  the  operations  themselves. 

Indications  for  Colotoniy. — (i)  Certain  cases  of  malignant  disease 
of  the  rectum.  I  say  "certain  cases"  advisedly,  for  it  is  far  too  much 
the  rule  to  recommend  colotomy  as  soon  as  rectal  cancer  is  detected,  as  if 
no  other  lines  of  treatment  existed;  and  it  is  too  much  the  habit  of 
students,  when  they  see  an  artificial  anus  neatly  made  in  these  cases, 
to  think  that  now  the  patient's  troubles  are  over.  In  reality  he  is  pro- 
bably only  exchanging  one  set  of  troubles  for  another. 

Where  obstruction  is  present,  impending,  or  threatening,  where,  in 
cases  which  are  too  advanced  for  excision,  there  is  extensive  ulceration.! 
gi'eat  pain,  difficult  defsecation,  loss  of  sphincter  power,  profuse  blood- 
stained or  f^eco-purulent  discharge  from  the  bowel,  or  multiple  fistulae, 
the  operation  is  abundantly  justified. 

In  less  urgent  cases,  if  the  surgeon  be  doubtful  as  to  recommending 
this  operation,  he  cannot  do  wrong  if  he  lay  stress  on  two  points — one, 

*  Students  are  frequently  perplexed  as  to  the  difference  between  Amussat's  and 
Calliscn's  operations.  Calliseu  (1796)  was  the  first  to  suggest  such  an  operation  as 
colotomy,  and  planned  to  open  the  descending  colon  by  a  vertical  incision.  This  pro- 
posal was  condemned  by  contemporary  surgeons.  Amussat  revived  the  retro-peritomeal 
operation,  if  he  was  not  the  first  to  perform  it,  but  modified  it  by  extending  it  to  the 
ascending  and  descending  colons  alike,  and  by  making  use  of  the  transverse  incision. 
Long  before  Amussat's  time,  Littre  (1710)  had  opened  the  sigmoid  flexure  through  the 
peritonaeum,  and  in  1776  Pillore  had  opened  the  ctecum. 

t  As  a  rule,  the  first  time  the  surgeon  examines  a  patient,  the  more  the  growth  tends 
to  become  annular,  the  less  limited  it  is  to  one  aspect  of  the  bowel ;  or  the  more  it 
projects  into  the  lumen  in  tuberous  masses,  the  more  likely,  cceteris  paribxis,  is  obstruc- 
tion to  threaten. 


86  OPERATIONS  OX  THE  ABDOMEN. 

that  there  is  always  the  risk  of  obstruction  setting  in,  and  none  can  say 
how  soon  this  may  call  for  colotomy  under  circumstances  much  less 
favourable;  the  other,  that  there  is  just  a  possibility  that  the  operation, 
by  diverting  the  faces,  will  arrest  the  rate  at  which  the  growth  would 
otherwise  spread. 

As  a  rule,  the  more  complete  the  failure  of  previous  treatment,  the 
more  painful,  difficult,  frequent,  and  unsatisfactory  the  action  of  the 
bo^^•els,  the  greater  the  tendency  to  distension  of  tire  sigmoid  or  lower 
intestines  generally,  the  more  frequent  the  attacks  of  gripings  and 
partial  obstructions,  which  herald  in  the  tormina  of  a  complete  miserere  ; 
the  younger  the  patient,  and  thus  the  longer  the  natural  prospect  of 
active  life,  the  more  plain  are  the  indications  for  colotomy.  On  the  one 
hand,  certain  special  evils*  call  loudly  for  the  relief  which  the  operation 
may  give — viz.,  a  patulous  or  invaded  sphincter  allowing  of  involuntary 
escape  of  flatus  and  fasces,  multiple  fistulge  giving  i-ise  to  foul  sanious 
discharge,  keeping  the  patient  (perhaps  a  woman  of  scrupulous  cleanli- 
ness) in  a  constantly  filthy  condition,  and  leading  to  a  brawny,  painful 
cxjndition  of  the  buttocks,  which  thus  readily  become  the  seat  of  cellu- 
litis and  its  allies ;  projection  of  the  growth  downwards  through  the 
anus,  leading  not  only  to  a  patulous  sphincter  and  its  consequent 
wretchedness,  but  also  to  irksome  or  painful  sitting. 

On  the  other  hand,  certain  conditions  contraindicate  the  operation — 
viz.,  exhaustion  of  strength,  evidence  of  secondary  deposits  in  the 
peritoneal  cavitj^  liver,  lungs,  or  pleura,  extension  to  the  inguinal 
glands,  and  absence  of  much  pain  or  obstruction  from  first  to  last. 

It  has  been  too  much  taken  for  granted,  because  rectal  cancer  is  often 
a  disease  of  much  suffering,  and  because,  from  the  inefficiency  or  neglect 
of  treatment,  obstruction  does  occur,  that,  when  cancer  of  the  rectum  is 
diagnosed,  the  patient  has,  therefore,  agonising  pain  and  obstruction 
to  look  forward  to.  The  above  view  is  quite  incorrect.  In  a  few 
cases  cancer  of  the  large  intestine  may  run  its  course,  and  set  up  visceral 
deposits  and  kill  the  patient  with  very  little  pain,  and  no  threatening  of 
obstruction t  whatever;  in  other  cases — and  they  form  a  considerable 
number,  and  would  be  still  more  numerous  if  efficient  treatment  were 
begun  early  and  persevered  with — careful  attention  to  diet,  regular 
use  of  laxatives,  .daily  washing  out  of  the  bo\\'el  with  warm  water  by  a 
soft  catheter  or  oesophagus-tube  passed  tliroiujh  the  stricture,  followed 
b}'  the  injection  of  starch  and  laudanum,  or  a  suppository  of  cocaine, 
iodoform,  and  morphia,  will  give  great  comfort  for  the  rest  of  the  day, 
entirely  prevent  obstruction,  and  enable  the  patient  to  get  about  and  go 
to  business  almost  to  the  last. 

Other   ever-important    points   on  which  the   patient  or  the  friends, 
especially  if  in  a  better  rank  of  life,  will  frequently  expect  a  decided 


'■'  To  quote  only  two  special  wretchednesses — e.g.,  when  a  lady  cannot  rise  from  her 
easy-chair  without  an  escape  of  flatus  or  fceces  taking  place  from  a  powerless  sphincter ; 
or  when  a  man  is  threatened  with  agonies  of  paiu  from  the  carcinoma  eating  back- 
wards and  involving  the  sacral  nerves,  and  causing  caries  of  the  sacrum  with  flstulae 
and  foul  discharge. 

t  lu  a  few  cases  the  growth  may,  instead  of  projecting  into  and  obstructing  the 
lumen  of  the  bowel,  have  led  by  ulceration  to  enlargement  of  the  gut  into  a  cavern-like 
soace. 


COLOTOMY.  87 

answer,  are — the  amount  of  relief,  and  also  the  amount  of  annoyance, 
which  will  follow  the  formation  of  an  artificial  anus. 

The  amount  of  relief  given  will  depend  on  the  amount  of  pain  the 
patient  has,  the  degree  to  which  obstruction  is  threatening,  or  the 
pi-esence  of  special  miseries  such  as  those  alluded  to  above.  Patients 
may  be  assured  that  any  continuous  pain  will  be  greatl}'  lessened  in 
severity,  if  not  entireh'  removed;  that  deftecation  will  become  easy, 
painless,  and.  after  the  first  four  or  six  weeks,  limited  to  one  motion  a 
day.  save  when  diarrhoea  is  present ;  and  that  the  distress  of  constant 
desire  to  go  to  stool,  and  tenesmus,  will  disappear.* 

The  other  part  of  the  question — the  amount  of  annoyance  following 
on  an  artificial  anus — must  be  honestly  met.  There  is  too  great  a 
tendency  amongst  writers  on  colotomy  to  teach  that,  if  the  operation 
is  done  sufficiently  early,  and  if  its  immediate  risks  are  survived,  the 
relief  is  ahcai/s  decided  and  the  patient's  condition  ahcays  a  most  satis- 
factory one.  This  tendency  has  largely  arisen  from  colotomy  being  so 
often  performed  on  hospital  patients  whom  it  is  so  difficult  to  keep  long 
under  observation.  While  it  is  always  right  to  remember  that  the  dis- 
ease is  a  mortal  one,  and  that  if  a  fair  comparison  is  to  be  made,  it  must 
be  not  between  the  condition  with  an  artificial  anus  and  that  of  perfect 
health,  but  between  an  artificial  anus  and  a  bowel  with  incurable  cancer, 
the  patient's  after-condition  will  be  materially  affected  by  his  position  in 
life.  Where  a  patient's  remaining  days  are  easy,  where  he  can  continue 
to  be  careful  in  his  food  to  avoid  diarrhoea,  where  he  can  pay  regular 
attention  to  the  opening,  this  may  give  little  annoyance ;  and  it  is  also 
a  rule  that  the  greater  the  miseries  of  pain,  and  frequent  and  difficult 
deftecation  from  which  the  patient  has  been  relieved  by  colotomy,  the 
more  easily  does  he  forget  any  annoyance  of  the  anus  in  his  relief  at 
what  he  has  escaped  from  in  the  past.  But,  on  the  other  hand,  where 
the  surroundings  of  the  patient  compel  him  to  try  and  work,  the  friction 
of  any  prolapsed  bowel  which  follo\\s  on  movements  of  the  thigh  and 
groin,  the  difficulty  of  paying  attention  to  the  opening,  of  avoiding 
diarrhoea  from  unsuitable  food,  of  washing  out  the  lower  bowel — all 
these  may  mean  that  colotomy  has  only  enabled  the  patient  to  exchange 
a  life  of  miseries  for  one  of  annoj'ances — the  annoyances  of  the  opening 
for  the  miseries  of  the  disease  ;  annoyances  certain!}"  less  important  but 
not  the  less  present  to  the  patient  because  they  were  unexpected.  And, 
as  I  have  said  before,  the  less  urgent  the  conditions  for  which  the 
colotomy  was  done,  the  less  the  patient  has  been  relieved  from,  the  more 
actively  will  the  annoyances  of  the  artificial  opening  be  present  to  his 
mind.  The  more  frequently'  a  surgeon  performs  this  operation,  the 
more  readily  will  he  admit  that  there  are  cases  in  which  colotomy, 
though  well  performed,  fails  to  give  the  expected  amount  of  relief. 

Putting  aside  cases  where  the  operation  is  performed  too  late,  and 
where  the  local  mischief  has  been  allo^\•ed  to  become  too  advanced,  those 
\\here  secondary  deposits  exist,  cases  where  the  opening  has  been  too 
free,  or  where,  with  a  proper  opening,  a  constant  cough,  aided  by  a 
relaxed  condition  of  tissues,  tends  to  bring  about  a  worrying  prolapsus, 
— putting  aside  cases  in  which  the  opening  was  perhaps  originally  too 

*  I.e..  if  the  opcuiug  is  free,  if  there  be  a  good  ••  spur."  aud  uo  fieces  find  their  way 
iuto  the  bowel  below. 


88  OPERATIONS  ON  THE  ABDOMEN. 

small,  or  in  which  the  patient  does  not  take  the  trouble  to  keep  the 
opening  dilated  as  directed, — I  am  of  opinion  that  occasionally  cases  of 
failure  to  give  complete  relief  are  met  with  after  an  operation  quite 
properly  carried  out.  While  I  cannot  give,  and  have  failed  to  meet, 
an  explanation  for  every  case,  I  think  the  following  are  bond  jide  cauties, 
and  without  detracting  seriously  from  the  value  of  this  excellent  opera- 
tion, because  only  occasional,  I  feel  that  they  have  been  somewhat 
unduly  overlooked. 

Some  of  these  instances  of  incomplete  relief,  viz.,  persistent  passage 
of  motions  over  the  malignant  disease,  and  teasing  diarrhoea  from  the 
artificial  and  natiiral  anus,  have  seemed  to  me  to  iDe  due  :  (a)  To  the 
lower  communication  with  the  bowel  being  too  patent,  sometimes  no 
doubt  accounted  for  by  the  fact  that  the  colon,  at  the  spot  where  it  has 
been  drawn  into  the  wound,  owing  to  the  shallowness  of  the  loin  or  the 
length  of  the  meso-colon,  is  scarcely  kinked  or  bent  at  all  ;  this  leads  to 
escape  of  faeces  over  the  malignant  growth,  and  much  pain  aiid  teasing 
diarrhoea.  (/')  To  persistence  of  the  growth  in  the  bowel  below,  causing 
a  profuse  sanious  discharge,  (c)  To  the  growth  extending  upwards 
towards  the  wound,  or  to  the  bowel  having  been  opened  only  just  above 
the  growth. 

(2)  Venereal  or  syphilitic  stricture  of  I'ectum,  in  which  previous 
treatment,  including  dilatation,  has  failed,  and  in  which  proctotomy*  is 
not  available. 

Much  of  wdiat  has  been  written  above  of  colotoniy  for  malignant 
disease  of  the  rectum  applies  to  the  operation  here  also.  There  is  one 
reason  for  resorting  to  it  earlier,  which  may  occasionally  arise,  and  that 
is  where  the  patient  is  young,  and  colotomy  is  called  for  by  extensive 
ulceration,  it  is  possible  that  with  the  rest  given  by  the  operation  the 
above  condition  may  be  healed,  and  the  artificial  opening  closed  later  on. 

(3)  Pelvic  tumours — e.;/.,  enchondroma  or  sarcoma — pressing  on  the 
rectum. 

(4)  Results  of  pelvic  cellulitis  narrowing  the  rectum. t 

(5)  Vesico-intestinal  fistula. 

Colotomy  is  performed  in  cases  of  communication  between  the  large 
intestine,  especially  the  rectum,  and  the  bladder,  to  prevent  the  passage 
of  fgeces  into  the  bladder,  with  its  results  of  cystitis,  agonising  obstiaic- 

*  Linear  division  of  a  non-malignant  stricture  posteriorly.  If  a  linger  cannot  be 
passed  through  the  stricture,  this  is  first  divided  with  a  probe-pointed  bistoury  to 
admit  the  finger.  Then  a  curved,  sharp-pointed  bistoury,  passed  through  the  stricture, 
is  made  to  transfix  the  bowel  beyond  the  stricture,  and  the  point  is  brought  out  close  to 
the  tip  of  the  coccyx.  The  parts  arc  then  cleanly  divided  by  cutting  out  towards  the 
anus  in  the  middle  line.  Most  strict  antiseptic  precautions  arc  necessary.  In  about 
ten  days  the  use  of  bougies  is  commenced. 

t  This,  though  rare,  is  occasionally  an  undoubted  indication  for  colotomy.  I  still 
see  from  time  to  time  a  woman  on  whom  Mr.  Howse,  over  eighteen  years  ago,  performed 
colotomy  for  urgent  obstruction  due  to  the  contraction  of  the  bowel  brought  about  by 
pelvic  cellulitis.  More  lately  I  have  had  under  my  care  a  woman,  aged  23,  a  patient 
of  Dr,  Howell's,  of  Wandsworth,  on  whom  chronic  obstruction  had  been  brought 
about  by  the  same  cause,  dating  here  to  the  birth  of  an  illegitimate  child.  The 
ring  of  contraction  round  the  rectum  was  here  so  marked,  that  carelessness  in  diet 
or  neglect  of  the  use  of  bougies  will,  I  am  certain,  lead  to  colotomy  being  ultimately 
called  for.  The  possibility  of  the  mischief  in  these  cases  being  gummatous  must 
always  be  remembered. 


COLOTOMY.  89 

tion  of  urine,  and  passa^^'e  of  flatus  from  the  uretlira  without  notice  and 
be^'ond  control. 

Such  a  fistula  is  much  more  frequenth*  met  with  between  the  sigmoid 
or  rectum  and  the  bladder;  if  between  the  latter  and  the  rectum,  the 
communication  may  be  found  by  the  finger,  or  by  passing  a  duck-bill 
speculum  and  injecting  coloured  fluids.*  Too  frequently  malignant  in 
character,  it  is  occasionally  of  a  simpler  nature — e.g.,  dysenteric,  &c., 
— and  so,  perhaps,  curable.  Thus,  in  Mr.  Holmes's  case  (Med.-Chir. 
Trans.,  vols.  xlix.  and  1.)  the  ulceration  between  the  sigmoid  and  the 
bladder  was  not  malignant,  colotomy  for  fifteen  months  M-as  most  suc- 
cessful, but  a  permanent  cure  was  prevented  by  similar  ulceration  taking 
place  between  the  csecum  and  bladder,  which  caused  death.  Whether 
the  cause  is  malignant  disease  or  no,  the  life  which  lies  before  the 
patient  is  scarceh'  tolerable. 

The  opening  is  far  more  frecjuently  valvular  in  natui'e — i.e.,  while  it 
admits  of  the  passage  of  fasces  into  the  bladder,  urine  very  rarely  passes 
per  anum. 

(6)  Colotomy  (iliac)  is  usually  performed  on  the  left  side  in  cases  of 
malformation  of  the  rectum,  when  this  part  of  the  intestine  cannot  be 
found  by  a  dissection  in  the  perineum.  It  has  been  disputed  in  these 
cases  whether,  after  an  unsuccessful  exploration  in  the  perinasum,  an 
iliac  or  a  lumbar  colotomy  should  be  performed.  The  great  majority 
of  svirgeons  have  preferred  the  former  operation,  following  here  Mr. 
Curling  (Diseases  of  the  Rectum,  p.  228).  This  surgeon  pointed  out  that 
the  lumbar  operation  was  contraindicated  on  the  following  grounds  : — 
(a)  The  death-rate  is  relatively  greater ;  (y8)  the  kidnej^  varying  in  size 
at  this  time  of  life,  may,  when  large,  overlap  the  colon ;  (7)  the  colon, 
instead  of  being  distended  with  meconium,  as  might  be  expected,  is 
sometimes  contracted  and  very  hard  to  find ;  (8)  in  addition  to  the 
irregularities  in  the  position  of  the  colon  which  have  already  been  men- 
tioned, a  meso-colon  is  frecjuenth^  present. f 

Mr.  Morrant  Baker,:J:  as  far  as  I  know,  was  the  only  surgeon  who  has 
of  late  years  advocated  the  lumbar  operation  in  cases  of  imperforate 
rectum.  His  reasons  appear  to  be  that  he  thinks  Amussat's  opera- 
tion gives  these  cases  ••  a  good  chance  of  an  unwounded  peritonaeum," 
and  that  those  who  think  Littre's  operation  the  better  one  do  so  on 
insuSicient  grounds.     It  is  noteworthy  that  Mr.  Baker's  case,  though 


*  The  foUoM-ing  plan,  based  upon  one  made  use  of  by  Mr.  Lund  {Hunt.  Led..  1885. 
p.  91).  would  very  likely  be  useful — viz.,  to  pass  into  the  rectum  a  bougie  round  which 
is  wound  a  strip  of  lint  well  soaked  in  starch-aud-water  and  dried,  and  then  to  inject 
into  the  bladder  some  diluted  iodine  solution.  A  stain  of  starch  iodide  on  the  bougie 
would  show  the  position  of  the  fistula. 

t  Mr.  Curling  (loc.  supra  cit.)  gives  the  results  of  twenty  dissections  on  the  bodies 
of  infants,  both  operations  having  been  first  performed.  In  eighteen  out  of  the  twenty, 
Littr6's  operation  was  found  easj',  whether  the  bowel  was  distended  or  no.  In  two, 
this  operation  failed,  as  the  colon  crossed  the  spine  to  run  down,  on  the  right  sitle,  into 
the  pelvis.  In  eight  out  of  the  twenty  subjects,  lumbar  colotomy  was  easily  performed, 
without  opening  the  peritonseum.  In  six,  the  operation  was  '•  more  or  loss  difficult," 
and,  as  Mr.  Curling  remarks,  the  difticulties  would  have  been  increased  in  the  living. 
In  six,  lumbar  colotomy  was  impossible  owing  to  the  distinctness  and  looseness  of  the 
meso-colon. 

X  Clin,  i^oc:  Trans.,  vol.  xii.  p.  240, 


90  OPERATIONS  OX  THE  ABDOMEN. 

mostsuccessful,  the  patient  being  alive  when  last  heard  of,  nearly  three  years 
after  the  operation — was  not  sent  to  him  till  the  nineteenth  day  after 
birth,  when  "the  abdomen  was  enormously  distended,  and  the  vomiting 
frequent,  and  the  child  much  exhausted."  No  doubt,  if  we  could  always 
thus  defer  operating  in  these  cases,  lumbar  colotomy  would  be  rendered 
much  safer,  but  the  peril  of  the  children  would  be  much  increased. 
But  from  my  experience  at  Guy's,  and  the  Children's  Hospital  with 
which  I  was  connected,  the  surgeon  is  called  upon  to  interfere  long- 
before  this. 

The  question  was  raised  by  M.  Huguier,*  wlietlier,  when  the  inguinal  operation  was 
going  to  be  performed,  the  right  side  should  not  be  chosen,  as  he  considered  that  on 
this  side  the  surgeon  was  more  certain  to  reach  some  part  of  the  large  intestine. 
M.  Giraldes.f  on  the  other  hand,  has  stated  that  all  the  inquiries  undertaken  to  eluci- 
date this  subject  tend  to  show  clearly  that  the  surgeon  may  rely  on  finding  the  sigmoid 
in  the  left  groin.  '•  Numerous  anatomical  investigations,  together  with  the  records  of 
those  of  Curling  and  Bourcart.  have  shown  me  that  in  the  great  majority  of  cases  in 
the  foetus  and  newly -born  child  the  sigmoid  flexure  is  jjlaced  on  the  left,  and  not  on 
the  right.  In  134  autopsies  below  the  age  of  a  fortnight  I  found  the  sigmoid  flexure 
on  the  left  side  in  114;  in  50  cases  of  Littre's  operation  which  I  have  collected  the 
operator  always  met  with  the  sigmoid  flexure  on  the  left  side ;  in  30  post-mortem 
examinations  of  infants  operated  on  for  imperforation  the  intestine  was  always  found 
on  the  left ;  in  100  examinations  of  new-born  children  Curling  found  the  sigmoid 
flexure  on  the  left  side  85  times;  and  Bourcart,  who  made  prolonged  researches  in 
order  to  elucidate  this  question,  found  the  sigmoid  flexure  in  its  normal  position  117 
times  out  of  150." 

(7)  Dysenteric  ulceration  and  stricture.  The  treatment  of  dysentery 
leading  to  stricture  is  rare :  when  it  occurs,  iilceration  may  extend  so 
high  up  the  large  intestine  as  to  make  even  a  right-sided  colotomy  of 
doubtful  value.  A  case  of  colitis  (the  nature  of  this  is  not  explained) 
with  ulceration,  treated  by  inguinal  colotomy  and  local  treatment  of  the 
ulcerated  surfaces,  with  subsequent  closure  of  the  artificial  anus,  is 
recorded  by  Mr.  Mayo  Robson  {Clin.  Soc.  Trans.,  vol.  xxvi.  p.  213).  In 
]iatients  who  give  a  history  of  long-standing  dysentery  and  stricture, 
dysentery  is  often  the  result  and  not  the  cause  of  the  stricture. 

(8)  Annular  stricture  of  the  sigmoid  colon. 

(9)  Malignant  disease  of  the  large  intestine  higher  up — viz.,  in  the 
splenic  or  hepatic  flexures. 

(10)  Membranous  colitis,  Mr.  Golding-Bird  has  described  two  cases 
in  which  he  has  performed  right  lumbar  colotomy  for  membranous 
colitis,  with  the  object  of  giving  rest  to  the  colon.  In  the  first  case 
(Clin.  Soc.  Trans..  1896)  the  colotomy  was  closed  after  five  weeks, 
as  all  s^-mptoms  had  disappeared.  The  patient  remained  quite  free 
from  symptoms  of  colitis  until  her  death,  which  took  place  two  months 
later.  In  the  second  case  (Guy's  Hosp.  Gaz.,  March  5,  1898)  the 
patient  was  quite  relieved,  and  was  fat  and  well  nine  months  after  the 
colotom}^  was  performed. 

Dr.  Lawrie,  of  Weymouth,  has  also  published  a  successful  case 
(Brit.  Med.  Journ.,  Nov.  5.  1898).  The  patient  was  47,  and  had  a 
history  of  membranous  colitis  of  eleven  years'  duration.      The  caecum 

*  Bull,  dc  VAcad.  de  Med.,  tom.  xxiv.  p.  445. 

t  Lcet.  Clin.,  p.  121.     Quoted  by  Mr.  Holmes  (^I)h.  of  Children,  p.  179). 


COLOTOMV.  91 

■was  opened  on  Janiiaiy  17.  1897,  the  wound  being  kept  open  for  seven 
montlis.     The  patient  was  well  in  Febriiarv.  1S98. 

As  a  much  rarer  indication  for  colotoniy  this  deserves  mention,  viz. : 
(11)  Cancer  of  the  tail  of  the  pancreas  obstructing  the  splenic  flexure. 
Mr.  Beck  records  a  case  of  this  kind  {Lancet,  vol.  ii.  1887,  p.  113): 

When  the  descending  colon  was  opened  neither  gas  nor  fiBces  escaped,  although  the 
abdominal  tension  caused  the  gut  to  protrude  through  the  wound.  The  finger  inserted 
into  the  colon  could  not  reach  the  seat  of  obstruction.  The  ascending  colon  was 
accordingly  opened,  and  a  large  quantity  of  gas  and  liquid  fasces  at  once  escaped.  The 
operation  gave  great  relief,  but  death  took  place  suddenly  (unexplained  by  the 
necropsy)  seventeen  days  later. 

Of  the  above  eleven  conditions,  the  first  five  will  usually  be  treated  by 
inguinal  colotomy,  this  operation  being  preferred  for  the  reasons  men- 
tioned below  (p.  loi).  as  long  as  the  abdomen  is  undistended.  The 
operation  chosen  in  the  seventh  must  depend  on  the  height  to  which  the 
disease  has  extended.  In  the  eighth  the  surgeon  will  be  justified  in 
cutting  down  upon  the  sigmoid  colon,  with  the  intention  of  excising  the 
disease  if  possible,  or  opening  the  bowel  above  it,  lumbar  colotomy 
being  only  resorted  to  if  neither  of  the  above  courses  is  found  feasible. 
In  the  last  two  it  will  be  needful  to  open  the  colon  high  up.  It  will  be 
well  to  discuss  here  the  difficulties  which  often  arise  in  deciding  as  to 

The  Site  of  the  Proposed  Colotomy. — In  the  above  cases,  espe- 
cially where  intestinal  obstruction  is  threatening  from  malignant  disease 
with  distension  and  tympanites,  the  surgeon,  particularly  if  the  history 
is  deficient  or  misleading,  may  be  in  doubt  as  to  the  site  of  the  disease, 
and  therefore  where  to  operate.  It  is  cjuite  impossible  to  make  fixed 
rules  for  advice,  but  the  following  points  will  help  in  doubtful  cases. 
Before  specifj'ing  them  I  would  call  attention  to  two  points :  one,  that 
malignant  disease  quite  low  down — e.g.,  in  the  sigmoid — may,  by  a 
sudden  onset  of  obstruction,  simulate  an  acuter  condition  of  things 
higher  up,  the  patient  being  too  ill,  or  otherwise  unable,  to  give  an 
account  of  previous  threatening  and  finally  culminating  obstructions. 
Here  the  following  alternatives  lie  before  the  surgeon:  (i)  to  explore 
the  site  of  obstruction  through  the  linea  alba  ;  (2)  to  cut  down  upon  the 
sigmoid  flexure  in  the  hope  that  the  obstruction  may  be  in  this  neigh- 
bourhood, a  very  common  place  ;  (3)  to  perform  right  lumbar  colotomy, 
so  as  to  make  sure  of  relieving  any  obstruction  further  back — e.;/..  in 
the  splenic  or  hepatic  flexures.  I  vrould  here  warn  my  junior  readers 
on  two  or  three  points.  If  they  decide  first  to  explore  by  abdominal 
section,  and  find  a  growth  in  the  colon,  descending  or  ascending,  they 
should  not,  even  if  the  meso-colon  admits  of  it,  bring  the  bowel  into  the 
middle  line  and  open  it.  Making  an  artificial  anus  in  the  colon  by  a 
median  iiicision  is  usually  a  matter  of  difficulty,  the  bowel  not  coming 
sufficiently  up  into  the  wound ;  thits  the  skin  has  to  be  forced  down  to 
it,  causina-  tension  on  the  sutures,  givino-  wav  of  these  a  little  later,  and 
either  disastrous  results  or  a  most  unsatisfactory  opening.  Lven  it  it 
were  usually  easy  to  cany  out  the  above  course.  I  do  not  consider  it 
would  be  good  surgery,  as  such  displacement  of  the  large  intestine  may 
lead  to  acute  obstruction  of  some  loop  of  the  small  intestine  later  on. 

I  also  advise  against  opening  the  cfecum  if  this  can  be  avoided. 
Owing  to  the  more  liquid  nature  of  the  fa?ces  here  from  the  close 
proximity  of  the  small  intestine,  though  the  patient's  nutrition  will  not 


92  OPERATIONS  OX  THE  ABDOMEN. 

suiFer,  the  skin  in  the  neighbonrhood  of  the  artificial  anus  is  liable  to 
most  troublesome  excoriations  and  ulceration. 

In  cases  where  the  surgeon  is  in  doubt  as  to  the  exact  site  of  the 
disease,  but  suspects,  from  the  age  of  his  patient,  duration  of  the  trouble, 
history  of  "  indigestion "  with  unsatisfactory  action  of  the  bowels, 
number  of  attacks  of  threatening  obstruction,  &c.,  that  the  mischief  is 
somewhere  in  the  large  intestine,  attention  to  some  of  the  following- 
points  may  be  useful : 

(i)  The  proportionate  frequenci/  of  stricture  in  different  parts  of  the 
large  intestine.  The  frequency  of  disease  in  the  rectum  and  sigmoid 
flexure,  as  compared  with  any  other  part  of  the  large  intestine,  and, 
generally  speaking,  the  frequency  of  disease  in  the  left  side  of  the  arch 
formed  by  the  large  intestine,  as  compared  with  such  disease  in  the 
right  side,  are  well  known,* 

(2)  The  use  oj  lanje  injections.  Dr.  Fagge  (Joe.  supra  cit.,  p.  318) 
thus  writes  on  this  subject : — "  Several  writers,  and  especially  the  late 
Dr.  Brinton,  have  laid  stress  on  the  value  of  large  injections  as  an  aid 
to  diagnosis.  The  observer  I  have  named  has  even  laid  down  definite 
rules  for  our  guidance  in  this  respect.  '  It  is  quite  singular,'  he  says, 
'  how  trustworthy  I  have  found  the  conclusions  thus  arrived  at.  For 
example,  with  a  maximum  injection  of  a  pint  of  warm,  bland  liquid  the 
obstruction  in  an  ordinary  male  adult  may  be  referred  to  a  point  not 
lower  than  the  upper  third  of  the  rectum.  A  pint  and  a  half,  two  pints, 
three  pints,  belong  to  corresponding  segments  of  the  sigmoid  flexure. 
The  descending  and  transverse  colon  accept  a  larger,  but  more  irregular, 
quantity.  In  one  case,  in  Avhich  it  was  evident  that  the  stricture 
occupied  the  upper  jDart  of  the  ascending  colon,  nine  pints  of  injection 
were  always  found  to  be  the  maximum.'  "  Dr.  Fagge  points  out  that  the 
correct  determination  of  this  point  requires  much  care,  as  (a)  some  of  the 
fluid  measured  may  escape  in  the  injection  ;  and  (/>)  a  stricture  may  be 
pervious  to  fluid  injection  from  below,  though  the  intestinal  contents 
may  be  unable  to  pass  through  it  from  above.  Thus,  in  a  case  in  which 
there  was  a  mass  of  disease  in  the  sigmoid  flexure,  just  above  the  pelvis, 
four  pints  of  water  were  injected  per  rectum ;  of  this  a  small  portion 
only  returned,  the  greater  part  passing  through  the  stricture  and  adding 
to  the  accumulations  above  it.  I  would  add  one  more  caution  with 
regard  to  these  injections.  Patients  in  much  misery,  and  having  sub- 
mitted to  one  or  two  rectal  examinations,  will  sometimes  ask  for  an 
anassthetic.  Such  an  aid  must  be  used  with  great  caution  if  there  is 
already  abdominal  distension.  There  is  not  only  a  danger  of  adding 
seriously  to  the  distension,  and  thus  further  M-eakening  or  rupturing 
parts  which  may  be  already  near  the  point  at  which  they  give  way — e.g., 
a  ca3cum  with  "  distension  ulcers" — but  an  anaesthetic,  especially  chloro- 
form, has  additional  dangers  in  such  cases  as  these,  where,  in  a  patient 
probably  no  longer  young,  the  action  of  the  heart  and  lungs  is  interfered 
with  by  the  upward  pressure  against  the  diaphragm.     The  vomiting, 

*  Dr.  Fagge,  in  drawing  attention  to  this  fact  {Guy's  IIosp.  Beports,  1868,  p.  314), 
quoted  the  following  statistics  from  Dr.  Brinton : — "  Of  100  cases,  4  are  in  the  caecum, 
10  in  the  ascending  colon,  11  in  the  transverse  colon,  14  in  the  descending  colon,  30  in 
the  sigmoid  flexure,  and  30  in  the  rectum."  The  statistics  of  Dr.  Fagge  and  M. 
Duchaussoy  coutirm  the  above. 


LUMBAR  COLOTOMY. 


93 


■whicli  the  angestlietic  may  caiise,  may  also  prove  suddenly  fatal,  fjEcal 
matter  beiiio-  sucked  down  into  the  lungs. 

(3)  The  distance  to  irhicJo  a  lomj  hoiKjic  or  rectal  tuhe  passes  is  of  very 
little  value,  and  needs  only  this  briefest  mention  here,  because  the 
surgeon  is  still  called  to  cases  in  which  he  is  assured  that  the  obstruc- 
tion cannot  be  in  the  rectum  or  low  down  in  the  sigmoid  flexure,  as  a 
long  bougie  has  l^een  easily  jiassed  its  full  length.  This  fallacy,  which 
is  due  to  the  bougie  bending  on  itself,  is  more  frequent  than  the  other 
one  in  which  the  arrest  of  a  bougie  by  one  of  Houston's  folds  misleads 
into  the  belief  that  a  stricture  exists  low  down. 

(4)  2Vie  form  of  the  abdomen  may  help  to  valuable  conclusions.  Thus, 
Dr.  Fagge  (loc.  supra  cit.,  p.  319)  gives  a  case  of  cancer  of  the  hepatic 
flexure  in  which  it  was  ol)served  during  life  that  the  caecum  and 
ascending  colon  were  distended,  and  not  the  descending  colon.  Again, 
he  observes  that  when  the  rectum  or  the  sigmoid  flexure  is  the  seat 
of  obstruction,  the  lumbar  regions  and  the  epigastrium  are  no  doubt 
generally  prominent,  and  the  course  of  the  colon  is  more  or  less  plainly 
marked  out.  That  these  conclusions  are  only  valuable  if  not  too  im- 
plicitly relied  upon  is  sho^^■n  by  the  "fact  that  cancer  of  the  rectum  may 
be  present,  with  vomiting,  ^peristalsis,  and  borborygmi.  and  yet  there 
may  be  no  general  distension  of  the  abdomen,  no  filling  out  at  all  of 
its  sides  ;  on  the  other  hand,  a  prominent  epigastrium,  and  the  appear- 
ance of  a  large  horizontal  coil  of  intestine  here,  mskj  lead  to  the  conclusion 
that  the  transverse  colon  is  distended,  the  disease  being,  nevertheless,  in 
the  ileum,  a  distended  coil  of  which  has  rivalled  the  colon  itself. 

(5)  A  symptom  of  some  value,  if  verified  by  the  medical  man  himself, 
is  the  fact  that  for  some  time  the  motions  have  been  narroic,  tape-Iil-e, 
iirolien  up,  ahnormal  in  hull;  shape,  andj  length.  Certain  fallacies  diminish, 
however,  the  value  of  the  above — e.g.,  that  in  cases  of  stricture  high 
up,  as  in  the  upper  part  of  the  sigmoid  flexure,  there  is  probably  room 
for  the  faeces,  after  they  have  got  through  the  stricture,  to  collect, 
till  their  characteristic  form  is  s'iven  them,  thouo-h  we  do  not  know 
how  far  irritation  of  the  intestine  and  formation  of  mucus  at  the  seat  of 
the  gr©\\'th  may  interfere  with  this. 

(6)  A  few  other  points — e.;/..  constant  arrest  of  horhwijgmi  at  one  spot, 
fixedj  pain  ai  one  spot,  as  in  the  right  hypochondrium  —  may  give  useful 
indications  ;  while  others,  such  as  a  rectal  examination,  are  so  obvious  as 
scai'cely  to  need  mention. 

If,  after  weighing  the  above,  the  surgeon  is  still  in  doubt  as  to  the 
exact  site  of  the  disease  of  the  large  intestine,  he  shoxild  not  hesitate  to 
open  the  abdomen  in  the  middle  line  and  explore  for  the  site  of  the 
disease,  or  perform  a  right-sided  lumbar  colotomy.  He  should  not  be 
deterred  from  this  latter  step  by  the  anatomical  difficulties  (e.r/.,  a  more 
complete  peritonceal  coat)  supposed  to  exist  on  this  side.  Especially 
where  the  colon  is  at  all  thickened  or  distended,  the  operation  on  one 
side  is  no  more  difficult  than  on  the  other. 

LUMBAR    OR    POSTERIOR    COLOTOMY. 

Though  this  operation  has  of  late  vears  been  verj-  largeh'  replaced  by 
the  iliac  method,  it  deserves  attention  as  the  operation  first  largely 
employed,  and  as  one  that  has  still  to  be  resorted  to  under  circumstances 


94 


OPEPvATIOXS  ON  THE  ABDOMEN. 


of  difficulty.  The  indications  for  this  operation  have  been  ah-eady  given 
at  p.  91,  and  a  comparison  of  the  lumbar  and  iliac  methods  will  be 
found  below  at  p.  loi. 

Landmarks  (Figs.  ^6  and  37). 

I.  The  lower  border  and  tip  of  the  last  rib.  2.  A  point  half  an  inch 
behind  the  centre  of  the  crest  of  the  ilium,  this  point  being  found  by 
accurate  measurement  along  the  crest  between  the  anterior  and  posterior 
superior  spines  (W.  Allingham).  3.  Aline  drawn  vertically  up  from  the 
last-mentioned  point  to  the  last  rib.  This  gives,  with  sufficient  correct- 
ness, the  line  of  the  outer  edge  of  the  quadratus,  and  the  position  of  a 
normal  colon.  Owing  to  the  varying  length  of  the  last  rib,  the  upper 
end  of  this  line  may  meet  this  bone  at  its  tip,  or  at  a  spot  a  varying 
distance  in  front  of  or  behind  this  point.  It  is  well  to  dot  the  ends  of 
this  vertical  line  with  an  aniline  pencil.  The  dint  of  a  finger-nail,  made 
when  the  patient  has  been  brought  under  the  ana?sthetic,  will  mark 
these  points  sufficiently  to  begin  with,  but  a  little  later,  in  a  difficult 
case,  the  surgeon  ma30je  glad  of  having  taken  every  possible  precaution. 

Fig.  36. 


Auiussat's  incision  for   lumbar  colotomy.     The  vertical    line  between  the  last  rib  and 
the  iliac  crest  is  the  guide  described  in  the  text.     (Heath.) 

Incisions. 

I.  Vertical,  of  Callisen.  This  at  first  sight  is  the  best,  as  it  follows 
the  above  line,  and  thus  corresponds  anatomically  to  the  colon,  but  it  has 
the  disadvantage  of  giving  but  limited  space,  especially  in  a  fat  or  deep- 
chested  patient ;  and,  if  prolonged  upwards,  so  as  to  give  all  the  space 
possible,  it  divides  the  intercostal  vessels  running  with  the  last  dorsal 
nerve,  and  gives  rise  to  troublesome  haemorrhage,  2,  Transverse, 
of  Amassat.  3.  Oblique,  of  Brj^ant,  modified  from  the  above.  One  of 
the  two  latter  is  usually  employed  ;  they  have  the  great  advantage  of 
being  readily  prolonged  when  more  room  is  required,  and  the  oblique 
incision  corresponds  better  with  the  course  of  the  nerves  and  vessels.* 
It  is  the  one  given  below. 


*  The  late  Mr.  Greig  Smith  {Abdom.  Surg.,  p.  396)  gave  the  following  practical 
hint : — "  lu  thin  patients,  and  particularly  in  women,  whose  iliac  crests  are  more 
prominent  than  in  men,  there  is  a  tendency  for  the  upper  lip  of  the  wound  to  fall 
inwards,  while  the  lower  lip  protrudes.  This  may  be  obviated  by  careful  apposition, 
and  by  not  bringing  the  line  of  the  incision  too  close  to  the  ilium," 


LUMBAR  COLOTOMV. 


95 


Operation  (Figs.  36-39). — The  patient  being  turned  on  to  his  side 
(most  usually  the  right),  with  a  firm  pillow  imder  the  loin,  the  parts 
cleansed,  the  tip  of  the  last  rib  and  the  point  on  the  crest  of  the  ilium, 
as  given  above,  being  dotted  with  an  aniline  pencil,  an  incision  is 
made,  beginning  2^  to  3  inches  from  the  spine,  according  to  the  size 
of  the  erector  spinse  a  little  below  the  last  rib,  and  running  downwards 
and  forwards  for  3 -J-  to  4  inches  towards  the  anterior  superior  spine. 
The  centre  of  this  incision  should  bisect  the  line  given  above  as  the 
line  of  the  colon. 

The  first  cut  should  expose  the  muscles,  the  skin  in  the  posterior  half 
being  thick,  and  the  subcutaneous  fat  often  abundant.  The  next  may 
go  well  into  the  muscles,  the  remainder  of  which  should  then  be  care- 
fully divided  with  the  knife,  so  as  to  expose  the  fascia  lumboruni ; 
any  bleeding  vessels  being  now  secured,  this  fascia  is  pinched  up, 
nicked,  and  slit  up  on  a  director.  Two  retractors  being  placed 
on  the  lips  of  the  wound,  the  fat  Avhich  lies  around  the  kidney 
and  behind  the  fascia  lamborum  is  next  torn  through  and  pulled 
away  with  the  fingers.  If  the  bowel  is  distended,  it  will  bulge 
up   into  the  wound,  pushing  before  it  the  transversalis  fascia,  and  the 


FiCx.  37. 


The  surgeon,  having  opened  the  h;mbai-  fascia,  is  dissecting  through  the 
transversalis  fascia  to  the  colon  itself.  The  two  crosses  mark  AUingham's 
line. 

operation  can  be  readily  completed.  If,  on  the  other  hand,  the  bowel  is 
emptj^,  the  real  difficulties  of  the  operation  only  begin  at  this  stage. 
The  wound  being  well  opened,  the  kidney,  if  it  come  down  below  the  rib 
(as  it  occasionally  does,  especially  in  a  patient  breathing  heavil}^  under 
the  influence  of  an  anaesthetic),  being  kept  out  of  the  way  by  the 
finger  of  an  assistant,  the  intestine  is  sought  for  by  scratching  with  a 
director,  or  two  pairs  of  forceps,  through  the  transversalis  fascia 
(Fig.  37),  exactly  in  the  line  to  which  attention  has  been  already 
drawn.  Several  layers  of  cellular  tissue  may  be  met  with  here,  and  it 
is  now  that  most  of  the  difficulty  is  usually  met  with,  owing  to  the 
operator  being  afraid  of  the  peritonfeum,  and  to  his  not  opening  the 
transversalis  fascia  with  sufficient  decision.  Unless  this  point  is  attended 
to  the  colon  cannot  bulge  satisfactorih'  or  be  drawn  up  into  the  wound. 
When  this  has  been  done,  scybala  in  the  colon  will  in  many  cases 
be  felt ;  but  if  the  large  intestine  is  empty,  much  trouble  may  be  met 


g6  OPEEATIONS  ON  THE  ABDOMEN. 

with  ill  detecting  it  and  getting  it  up  into  the  wound,  especially  if,  close 
by,  the  peritonaeum  is  bulging  up. 

At  this  stage  the  following  points  may  be  useful!}^  remembered : — 
(a)  The  exact  position  of  the  line  of  the  colon  (p.  94).  (/>)  The 
lower  end  of  the  kidney,  and  its  relation  to  the  colon,  (c)  The  outer 
edge  of  the  quadratus  lumborum  (p.  94).  {d)  The  sensation  of 
thickness  as  given  to  the  fingers  in  pinching  u])  the  colon,  thus  dis- 
tinguishing large  from  small  intestine.  (e)  The  feel  of  scybala  if 
present.  (/)  Seeing  one  of  the  three  longitudinal  muscular  bands  which 
distinguish  the  colon.*  (f/)  Inflation  with  air  or  injection  of  fluid.f 
(A)  Mr.  Bryant  has  advised  rolling  the  patient  over  on  to  his  back  at 
this  stage,  so  that  the  colon  ma}*  be  felt  to  fall  on  the  finger  inserted 
deep  into  the  wound. 

The  bowel  having  been  found,  its  posterior  surface  is  to  be  drawn 
well  up  into  the  wound.  This  is  one  of  the  weak  points  of  the  lumbar 
operation.  Owing  to  the  shortness  of  the  meso-colon  and  the  fixity 
of  the  bowel,  especially  when  distended,  it  is  very  difficult  to  get  the 
bowel  out  of  the  wound  sufficient!}'  to  make  a  satisfactory  "  spur."  Unless 
this  is  done  there  is  a  risk  of  the  patient  having  a  faecal  fistula  instead 
of  an  artificial  anus.  If  the  case  is  not  an  urgent  one,  the  bowel,  when 
well  pulled  up.  may  be  retained  there  by  means  of  a  rod  passed  beneath 
it  as  described  below  (page  104).  If  the  shortness  of  the  meso-colon 
prevents  the  use  of  a  straight  rod,  this  must  be  suitably  curved,  so  that 
the  bowel  may  still  be  kinked,  but  without  undue  tension.  The 
margins  of  the  wound  are  then  carefully  closed  with  silver  wire  or  salmon 
gut  sutures,  and  a  few  fine  ones  may  be  passed  between  the  bowel  itself 
and  the  margins  of  the  wound.  The  usual  antiseptic  dressings  are  then 
applied,  iodoform  being  dusted  over  the  bowel  and  wound.  These 
dressings  will  probably  not  need  changing  till  the  fourth  day,  when 
the  operation  is  completed  by  opening  the  bowel  with  a  tenotomy-knife. 
This  opening  may  be  a  small  crucial  one.  Very  little  but  flatus 
Avill  pass  at  the  time,  but  a  director  will  show  the  presence  of 
faeces,  and  mild  aj^erients  may  be  given  as  soon  as  the  parts  are 
firmly  healed. 

♦  Mr.  H.  AUinghani  (Brit.  Med.  Journ..  April  28,  1888)  seems  to  consider  it  very 
difficult  to  ensure  finding  one  of  these  bands  without  opening  the  pcritonaeal  cavity. 
"While  I  should  be  the  last  to  make  light  of  the  difficulties  which  may  beset  this 
operation,  I  feel  sure  that  few  surgeons,  who  have  had  a  large  experience  of  colotomy, 
will  agree  that  the  above  step  is  needful,  especially  if  the  line  given  by  Mr.  AUingham's 
father  be  strictly  followed.  Where  the  operation  is  done  in  two  stages  the  peritonasum 
may  be  opened,  if  needful,  without  any  drawback.  But  where  the  bowel  must  be  opened 
at  once — and  this  will  be  the  rule  in  lumbar  colotomy — any  injury  to  the  peritonaeum 
is  to  be  avoided.     The  aphorism  quoted  at  p.  53  is  to  be  remembered  here  also. 

t  Air  is  most  readily  made  use  of.  It  may  be  pumped  in  by  a  Higginson's  syringe, 
a  Lister's  hand-spray,  but,  best  of  all,  by  the  special  apparatus  described  by  Mr.  Lvmd 
(^Lancet,  1883,  vol.  i.  p.  588),  which,  by  means  of  an  clastic  ring,  secures  air-tight 
contact  with  the  anus  while  air  is  being  pumped  in,  either  as  an  aid  in  colotomy 
or  as  a  means  of  reducing  an  intussusception.  In  some  cases  of  cancerous  disease 
of  the  rectum  it  Avill  be  very  difficult  to  introduce  any  nozzle  for  inflation  beyond  the 
disease.  In  the  summer  of  1885,  when  performing  colotomy  at  Guy's  Hospital  in  a 
patient  the  lower  part  of  whose  rectum  had  been  unsuccessfully  excised  at  another 
hospital,  I  found  it  impossible  to  introduce  any  nozzle  when  desirous  of  inflating  an 
empty  colon. 


LUMBAR  C0L0T03IY. 


97 


The  method  of  performing  colotomy  by  two  stages  was  intro- 
duced at  Guy's  Hospital  by  some  of  my  senior  colleagaies,  Mr.  Bryant, 
Mr.  Howse,  and  Mr.  Davies-Colley,  being  based  on  that  most  im- 
portant modification  of  gastrostomy  which  Mr.  Howse  was  the  first 
to  make  use  of  in  this  country,  Mr.  Davies-Colley  bringing  before 
the  Clinical  Society,  in  1885  {Trans.,  vol.  xviii.  p.  204),  a  paper  on 
"  Three  Cases  of  Colotomy  with  Delayed  Opening  of  the  Intestine." 
The  great  advantages  of  this  two-stage  method  are  (i)  that  it  defers 
the  opening  of  the  bowel  till  this  is  siifficiently  adherent.  (2)  By 
this  delayed  escape  of  intestinal  contents  the  gravity  of  any  injury 
to  the  peritonaeum  at  the  time  of  the  oj)eration  is  very  much 
diminished.  (3)  The  second  great  trouble  after  colotomy — that  of 
burrowing  suppuration  up  and  down  the  planes  of  cellular  tissue, 
which  have  of  necessity  been  freely  opened — is  done  away  with.  The 
opening  of  the  intestine  being  delayed,  primaiy  union,  to  a  very  large 
extent,  can  be  secured,  especially  with  the  aid  of  deeply-passed  sutures, 
or  of  chromic  gut  ones  cut  short  and  dropped  in.  and  dry  dressings. 

But,  nowadays,  under  the  conditions  in  which  lumbar  colotomy  is 
usually  resorted  to — viz.,  obstruction  and  distended  intestine — it  will 
be  necessary  to  complete  the  operation  at  one  stage.  Here  the  dis- 
tension, and  the  difficulties  consequent  upon  it,  are  best  met  by  tying 
in  a  Paul's  tube.  The  wound  having  been  closed  as  far  as  is  possible, 
the  intestine  is  drawn  out,  and  the  surrounding  parts  are  shut  off  with 
sterile  gauze ;  a  small  opening  is  then  made  in  the  intestine,  the  tube 
inserted  and  tied  in,  and  the  patient  turned  on  to  his  back  while 
the  chief  of  the  accumulation  in  the  intestine  is  allowed  to  run  away 
safely.  When  sufficient  relief  has  been  given,  the  bowel  maj'  be 
additionally  secured  by  some  sutures  between  it  and  the  lips  of  the 
wound.  The  wound  having  been  carefully  shut  off  with  dressings, 
the  faeces  are  collected  by  means  of  india-rubber  tubing  fitted  on  to 
the  tube,  soiling  of  the  dressings,  &c.,  being  prevented  by  jaconet. 

If  a  Paul's  tube  is  not  at  hand,  the  bowel  must  be  well  drawn 
out  of  the  wound  and  carefully  isolated  by  means  of  plenty  of 
iodoform  gauze.  The  patient  being  then  turned  on  his  back  and 
brought  over  the  edge  of  tlie  table,  the  wound  is  carefully  shut  off 
with  temporary  dressings,  and  the  bowel  opened  either  by  a  trocar 
of  calibre  sufficient  to  admit  a  piece  of  drainage-tube  if  the 
contents  are  fluid,  or  by  an  incision  into  the  gut,  which  is  well 
pulled  out  and  held  over  some  appropriate  receptacle  for  the 
escaping  fasces.  While  these  are  coming  away  the  wound  should 
be  carefully  irrigated.  As  soon  as  the  chief  distension  has  been 
relieved,  the  opening  should  be  temporarily  closed,  while  the  colon, 
now  somewhat  collapsed  and  easier  to  deal  with,  is  carefully  sutured, 
with  silk  that  is  not  too  fine,  to  the  edges  of  the  wound,  which 
is  well  dusted  with  iodoform,  or  painted  over  with  iodoform  and 
collodion.  If  the  distension  be  not  sufficiently  relieved,  the  means  for 
temporarily  closing  the  colon  must  be  next  removed,  and  the  wound, 
which  has  been  carefully  closed  and  sealed  around  the  opened  colon, 
kept  as  clean  as  possible  by  frec[uent  dressing.  The  parts  around 
must  be  kept  smeared  with  an  ointment  of  eucalyptus  and  vaseline, 
while  the  dressings  themselves  are  kept  in  position  by  a  many-tailed 
bandage,  by  which  means  they  are  readily  and  painlessly'-  renewed. 
VOL.   II.  7 


98 


OPERATIONS  ON  THE  ABDOMEN. 


Fic.  38. 


Lumbar  oolotomy,  showing 
the  old  method  of  opening  and 
fixing  the  colon.     (Heath.) 


The  old  operation  of  opening  the  bowel  at  once  was  easy  but  perilous 

(tide  Fig.  38).  A  ligature  having  been 
passed  first  through  one  lip  of  the  wound, 
then  across  the  bowel  and  through  the 
opposite  lip,  and  another  in  the  same  way 
aliont  half  an  inch  from  the  first,  an  in- 
cision three-quarters  of  an  inch  long  was 
then  made  into  the  gut,  over  these  sutures, 
their  centre  hooked  up  into  the  woimd, 
and  the  four  halves  tied  on  either  side,  a 
few  other  sutures  being  put  in  between 
the  cut  lio\\'el  and  the  wound.  But  in 
this  case  there  was  always  some  risk  of 
fsecal  matter  or  flatus  being  forced  into 
the  different  planes  of  cellular  tissue, 
especially  if  the  bowel  was  much  dis- 
tended, even  if  precautions  were  taken  to 
keep  the  knuckle  well  up,  and  to  close  the 
wound  thoroughly  around  it. 

If  the  bowel  is  full  of  scybala  no  attempt 
should  be  made  to  remove  them ;  they  may 
be  left  until  aperients  can  be  safely  given. 
At  times  the  bowel  seems  so  empty  as  to 
suggest  a  failed  operation :  there  is  no 
occasion  to  be  troubled  at  this ;  the  contents  will  pass  shortl3^ 
Difficulties  in  Lumbar  Colotomy. 

I.  An  empty  liowel.*  This  has  been  already  alluded  to  (p.  95). 
2.  Mistaking  bulging  peritona3um  for  colon,  and  opening  it.  This 
may  be  due  to  the  surgeon  forgetting  the  line  of  the  bowel,  and 
working  deeply  too  far  forwards  ;  or  it  may  take  place  from  no  fault 
of  the  surgeon,  being  due  to  the  presence  of  a  meso-colon,  or  to  the 
extremely  contracted  condition  of  the  colon.f     It  by  no  means  always 

*  It  is  noteworthy  that  the  intestine  may  be  found  empty,  even  in  obstructions 
of  long  continuance.  Thus,  Mr.  Curling  (^Diseases  of  the  Rectvin,  p.  182)  writes:  "In 
a  case  of  carcinomatous  stricture  of  the  rectum,  in  which  I  performed  colotomy  after 
a  month's  obstruction,  in  a  woman  aged  40,  not  only  was  the  colon  contracted,  but 
it  was  actually  compressed  against  the  spine  and  put  out  of  the  way  by  the  distended 
small  intestine,  so  that  it  was  impossible  to  reach  the  bowel  without  opening  the 
peritonaeum.  No  inflammation  or  unfavourable  symptom  resulted."  It  would  have 
been  interesting  to  know  whether  more  than  one  obstruction  did  not  exist  in  the  large 
intestine  in  this  case. 

t  In  a  case  in  which,  owing  to  the  extreme  pain  during  defaecation,  the  patient  had 
dreaded  any  action  of  the  ])owels,  and  had  eaten  very  little,  the  colon  was  much 
contracted  and  lay  far  liack.  In  trying  to  find  it,  I  opened  the  peritonsBum,  and 
omentum  protruded.  A  carbolised  sponge  was  kept  over  the  opening  while  the  colon 
was  found,  the  opening  then  tied  up  with  chromic  gut,  and  the  colon  not  opened 
for  four  days.  No  ill  result  followed.  As  in  supra-pubic  lithotomy,  the  peritonaeum 
may  give  way  during  vomiting.  Thus,  Dr.  Walters  {Brit.  Med.  Journ.,  1879,  vol.  i. 
p.  212)  was  stitching  the  colon  to  the  wound  when  '-the  patient  retched  violently, 
causing  the  pcritomeum  to  give  way,  and  a  coil  of  intestine  to  protrude  from  the 
anterior  part  of  the  wound.  This  was  immediately  covered  with  warm  sponges, 
cleansed  from  the  fieculent  matter  it  had  acquired  by  contact  with  the  open  colon, 
and  returned."  When,  five  weeks  later,  the  patient  sank  from  exhaustion,  no  trace 
of  peritonitis  was  found  at  the  necropsy. 


LUMBAE  COLOTOMY.  99 

causes  peritonitis.  When  this  accident  has  happened,  as  shown  La- 
the  escape  of  a  Kttle  serous  fluid,  the  appearance  of  a  coil  of  small 
intestine  or  of  omentum,  the  opening  should  be  at  once  taken  up 
with  dissecting-forceps  and  tied  round  with  carbolised  silk  or  chromic 
gut,  and  a  little  iodoform  rubbed  round  the  ligature.  If  the  opening- 
be  larger,  it  must  be  closed  with  catgut  sutures.  3.  A  very  fat  loin. 
This  is  not  a  ver}'  uncommon  source  of  difficulty  in  elderly  people  who 
require  colotomy.  It  must  be  met  by  a  very  free  incision  in  which  all 
the  tissues  are  cut  equally  throughout  (i.e..  not  making  a  conical  wound 
deep  only  in  its  very  centre :  this  not  only  adds  to  the  difficult}^  of 
finding  the  bowel,  but  also  of  retaining  it  in  situ  afterwards).  To  meet 
the  additional  tension  and  tendency  of  the  gut  to  drag  awa}'  in  these 
cases,  it  must  be  more  carefully  secured  by  close  stitching,  especially 
if  it  is  necessary  to  do  the  operation  in  one  stage,  every  care  being 
taken  to  prevent  extravasation  of  faeces  into  the  surrounding  cellular 
tissue.*  In  fat  people  the  surgeon  must  be  prepared  not  only  for 
much  subcutaneous  but  for  abundant  extra-peritonseal  fat  also,  coarse, 
and  difficult  to  dissect  in.  If.  in  such  a  case,  the  colon  is  contracted, 
there  are  few  more  difficult  operations.  4.  Presence  of  a  meso-colon. 
This  may  be  a  cause  of  much  difficulty  and  doubt,  and  render  opening 
of  the  peritona3um  necessary-.  Where  this  is  the  case,  the  surgeon 
should  always  defer  opening  the  colon  if  possible. 

Mr.  Jessop  (Brit.  Med.  Jonrn..  1879,  vol.  ii.  p.  614)  mentions  cases  in  which,  owing 
to  the  presence  of  the  above,  he  was  obliged  to  open  the  peritoneal  cavity  and  incise 
the  gut  through  its  peritonaeal  coat.  The  cut  edges  of  the  bowel,  brought  through  the 
opening  in  the  peritonaeum,  were  stitched  to  the  skin  as  in  the  ordinary  operation. 
No  bad  effect  followed.  Mr.  Bennett  May  (^Brit.  Med.  Joitrn.,  1882,  vol.  i.  p.  940). 
operating  on  the  right  side,  found  an  empty  colon,  "and  it  was  only  by  keeping 
strictly  in  AUingham's  line,  and  patiently  searching  there  between  the  layers  of  a 
great  length  of  meso-colon.  that  the  intestine  was  reached,  collapsed  and  empty." 

5.  Abnormality  of  colon.  Every  surgeon  must  remember  cases  in 
which  the  descending  colon,  though  present,  was  displaced,  and  came 
■down  in  the  middle  line.  Occasionally  part  of  the  large  intestine  is 
actually   absent. 

Mr.  Lockwood  (St.  Barthol.  Hosj^.  Reports,  vol.  xxix.  p.  256)  mentions  three  cases 
in  which  the  colon  could  not  be  found ;  in  two  its  absence  was  verified  at  the 
necropsy,  both  on  the  right  side.  One  of  these  cases  is  reported  fully.  The 
following  are  the  main  points : — Owing  to  obstruction  of  the  large  intestine,  the 
site  of  which  was  doubtful,  it  was  decided  to  cut  down  on  the  right  colon.  No  colon 
could  be  found,  and.  relief  being  imperatively  demanded,  the  peritonaeum  was  opened 
and  a  loop  of  small  intestine  drawn  outside  the  wound.  Death  occurred  four  hours 
after  the  operation,  and  at  the  necropsy  the  right  colon  was  quite  absent.f  the  cagcum 
being  found  behind  the  liver  in  the  right  hypochondrium.  the  large  intestine  extending 
from  this  to  the  splenic  flexure  in  the  usual  manner. 

*  As  much  of  the  wound  as  is  possible  should  be  closed  before  the  intestine  is 
opened. 

t  Mr.  Lockwood  {Brit.  Med.  Joxrn..  1882,  vol.  ii.  p.  574)  explains  the  abnormalities 
of  the  large  intestine  by  the  fact  that,  during  its  development,  it  is  very  mobile  :  the 
caecum  occupying  first  the  umbilical,  then  the  left,  next  the  right  hypochondrium.  and. 
finally,  the  right  iliac  region,  abnormalities  may  follow  its  arrest  at  any  part  of  its 
.course. 


lOO  OPERATIONS  ON   THE  ABDOMEN. 

If  the  colon  cannot  be  found,  three  courses  are  open  to  the  surgeon — 
(a)  To  open  the  small  intestine  through  the  peritonseuni  from  the  colo- 
tomy  incision.  The  objections  to  this  step  are  that  it  is  very  fatal, 
and  that  there  is  no  telling  what  part  of  the  small  intestine  is  opened. 
(/S)  To  perform  colotomy  on  the  opposite  side,  and.  if  the  colon  is  here 
distended,  to  open  it,  in  two  stages  when  practicable.  This  is  the  course 
that  should  alwa3'S  be  followed  if  possible,  (y)  If  no  colon  can  be 
found,  or  if  the  part  found  is  below  the  obstruction,  the  linea  alba  should 
be  opened  to  admit  two  fingers  to  explore  for  the  displaced  colon,  and  if 
no  colon  can  be  found,  to  draw  up  and  attach  a  loop  of  small  intestine, 
chosen  as  near  the  cEecum  as  possible.  Or  Nelaton's  operation  may  be 
performed,  this  being  the  wiser  step  if  the  patient  is  exhausted  by  a 
previous  prolonged  operation.  6.  Malignant  disease  at  the  site  of 
colotomy.  This  is  best  met  by  performing  colectomy  in  appropriate 
cases,  or  by  perforniii:ig  colotomy  on  the  opposite  side.  7.  The  kidney 
may  be  embarrassingly  low.  8.  The  peritonaeum  may  be  so  pushed 
back  by  ascitic  fluid  that  it  is  impossible  to  open  the  gut  without 
injuring  the  peritoneum  (Pepper,  La/tce^,  vol.  i.  1888,  p.  772).  9.  Cases 
where  the  operation  has  to  be  completed  at  once,  and  the  colon  is  much 
distended  with  feces,  will  give  much  trouble  (p.  97). 

Troubles  which  may  be  met  with  after  Colotomy. 

1.  Too  large  an  opening  in  the  bowel.  This  may  lead  to  pro- 
lapse of  the  mucous  membrane.  If  this  take  place  to  a  large  extent 
it  is  a  great  nuisance  to  the  patient,  owing  to  the  moist,  excoriated, 
bleeding  surface  which  results,  difficult  to  keep  up  by  any  apparatus. 
Even  where  the  opening  has  been  small,  a  good  deal  of  prolapse 
may  take  place  if  there  is  much  cough  and  a  flaccid  condition  of  the 
side. 

2.  Too  small  an  opening  in  the  bowel.  This  is  of  much  less  moment, 
as  it  can  be  readily  dilated  by  tents.  Of  these,  laminaria  are  much  the 
most  efficient ;  two  should  be  inserted  at  a  time,  to  effect  rapid  dilata- 
tion. Then  the  opening  is  easily  kept  patent  by  the  occasional  insertion 
of  the  little  finger,  and  by  the  wearing  of  a  proper  plug.  (See  also 
p.  108.) 

3.  Teasing  descent  of  scybala  into  the  bowel  below  the  artificial  anus. 
This,  which  often  renders  a  colotomy  disappointing,  is  best  met  by 
bringing  the  colon  si^fficiently  into  the  wound  at  first,  and  by  keeping 
patent  an  adequate  opening.  If  scybala  still  find  their  way  down,  the 
colon  may  be  washed  out  from  the  anus  or  the  wound.  If  these  fail,  the 
only  course,  and  one  not  devoid  of  risk,  is  to  open  up  the  wound,  to 
divide  the  bowel,  and  attach  the  upper  end  in  the  wound,  and  then  tO' 
suture  the  lower  end  and  drop  it  in.  This  last  step  can  only  be  taken 
with  safety  if  this  part  of  the  bowel  is  empty  (p.  107). 

Causes  of  Death  after  Colotomy. 

These  will  vary  somewhat  according  to  the  presence  of  obstruction  or 
no.  I.  Exhaustion.  Especially  if  the  operation  has  been  deferred  too 
long.  2.  Toxic  conditions  probably  due  to  the  continued  distension  of 
the  intestines,  and  the  resulting  absorption  by  the  patient  of  poisonous 
material.  3.  Extravasation  of  faeces  and  burrowing  suppuration.  This 
is  especially  liable  to  happen  in  very  fat  patients,  in  whom  there  is  a 
difficulty  in  getting  the  colon  up  into  the  wound,  especially  if  the  bowel 
must  be  opened  at  once.     As  the  feces  pump  out  under  high  pressure,. 


IXGUIXAL  COLOTOMY.  lOI 

a  sufficiently*  free  opening   should  in  these  cases   be   made    into   the 
bowel  after  this  has  been  secured  as  carefully  as  possible  (p.  97). 

4.  Peritonitis.  This  may  be  due  to  the  operation  directly,  or  more 
indirectly  from  fa3cal  or  purulent  retro-peritongeal  extravasation,  or  from 
septicaemia.  Often  it  is  not  due  to  the  operation,  but  to  the  want  of  it 
a,t  an  earlier  stage.  Thus,  the  distended  bowel  may  have  given  ■way  just 
above  the  obstruction  ;  often  it  is  that  weak  spot  the  caecum  which  is 
found  perforated  after  the  stress  of  distension,  f 

5.  Septic  cellulitis,  erysipelas,  &c.  These  are  not  always  preventable 
in  an  exhausted  patient  where  it  has  been  necessarj-  to  open  the  bowel 
at  once.  6.  Vomiting.  This  has  been  noticed  in  a  few  cases  to  occur 
obstinately  and  fatally  after  colotomy.  Mr.  Couper  [Brit.  Med.  Joiirn., 
1869,  vol.  ii.  p.  557)  thinks  that  it  is  not  an  infrequent  cause  of  death,  and 
suspects  that  traction  on  the  bowel,  its  proximity  to  the  stomach,  and 
the  fact  that  both  receive  nerves  from  the  solar  plexus  will  account  for 
this.  7.  Broncho-pneumonia,  pleuritic  effusion,  especiallj'  if  the  wound 
has  become  septic  in  an  exhausted  patient. 

INGUINAL,   ILIAC,   OR  ANTERIOR   COLOTOMY. 

Of  late  3-ears  there  has  been  an  increasing  tendency  for  this  to  replace 
the  lumbar  operation  in  the  majority  of  cases  which  call  for  colotomy 
(vide  supra,  p.  91). 

The  advantages  claimed  for  the  iliac  operation  are  chiefly — (i.)  It  is 
easier.  Thus,  (a)  the  patient,  being  on  his  back,  takes  the  ana3sthetic 
better  than  when  rolled  on  his  side ;  (/3)  In  a  stout  patient,  especially, 
the  soft  parts  are  easier  to  divide,  and  the  resulting  wound  less  deep 
and  more  readily  dealt  with  than  one  in  the  loin  :  (7)  The  bowel  is  more 
easily  reached,  and  with  less  disturbance  of  deep-lying  soft  parts ; 
(S)  There  is  no  risk  of  oj)ening  small  intestine,  or  of  failing  through 
abnormality  of  the  colon,  (ii.)  The  peritona?um  being  opened  of  set 
purpose,  the  surgeon  can  examine  the  site  and  extent  of  the  disease, 
(iii.)  The  shallower  wound  makes  it  much  easier  to  draw  out  the  intes- 
tine, and  make  a  satisfactory  angle  and  spur,  or  to  perform  colectomy, 
(iv.)  The  position  of  the  anus  renders  it  more  easily  accessible  for  the 
needful  attention. 

If  the  above  advantages  are  considered  separately,  I  think  there  is 
no  doubt  that  the  first  (and  this  is  the  most  important  one)  is  correct. 
"Where  the  colon  is  distended,  the  lumbar  operation  is  an  easy  one;  but 
where  the  bowel  is  flaccid  and  lies  deeply  far  away  in  a  fat  patient,  the 


*  Not  needlessly  large,  for  fear  of  troublesome  prolapsus  later. 

t  The  following  reasons  have  been  given  in  explanation  of  this  well-known  fact — 
viz..  the  proneness  of  the  cascum  to  give  way  under  the  stress  of  distension,  and  even 
when  at  some  distance  from  the  obstruction.  Dr.  Coupland  and  Mr.  Morris  (Brit.  Med. 
Journ.,  1878)  attribute  it  to  the  cul-de-sac  nature  of  this  part  of  the  intestine;  its 
lixity  and  dependent  position ;  its  being  the  place  where  two  currents  meet — viz..  from 
the  ileum  and,  in  case  of  regurgitation,  from  the  colon;  and  the  pressure  to  which  it 
is  subjected  between  the  iliacus  and  the  abdominal  muscles.  Mr.  Lockwood  {St.  Bart. 
]Io.<p.  1,'cports.  vol.  xix.  p.  26)  thinks  that  the  explanation  lies  rather  in  the  peculiarity 
of  structure  of  the  cascum,  as  it  contains  a  very  large  amount  of  lymphoid  tissue,  and 
as  its  walls  arc  not  strengthened  equally  with  other  parts  of  the  large  intestine  by 
encircling  bands. 


102  OPERATIONS  ON  THE  ABDOMEN. 

operation,  in  spite  of  the  aids  given  at  p.  96,  is  one  of  the  most  difficult 
in  all  surger3^  I  am  speaking  now  from  an  experience  of  twenty-nine 
cases  of  my  own  and  a  large  number  which  I  have  seen  performed  by 
my  colleagues.  Iliac  colotom3^  with  the  thinner  soft  parts,  the  deliberate 
opening  of  the  peritonteum,  and  the  more  accessible  colon,  is  a  far  easier 
and  simpler  operation.  The  second  advantage  claimed — that  an  iliac 
colotomy  enables  the  surgeon,  by  opening  the  peritoneal  cavity,  to 
examine  into  the  site  and  extent  of  the  disease — will  be  found  an 
important  one  (as  in  cases  of  annular  or  limited  disease  of  the  sigmoid, 
when  removal  of  the  growth  may  be  possible,  or  when  the  surgeon  is 
uncertain  as  to  the  site  of  the  growth,  but  hopes  that  an  inguinal  colo- 
toni}'  may  open  the  disease  above  it).  The  third  advantage  is  an 
important  one  in  those  cases  where  a  deep  wound  loaded  with  fat  makes 
it  very  difficult  to  bring  up  and  anchor  a  lumbar  colon  satisfactorily. 
On  the  fourth  point,  on  which  much  stress  has  been  laid — that  an  arti- 
ficial anus  in  front  is  placed  more  satisfactorily  for  the  patient's  needs 
than  one  in  the  lumbar  region — there  is  something  to  be  said  on  both 
sides.  A  patient  with  an  artificial  anus  in  front  can  clean  this,  adjust 
the  pad,  and  wash  out  the  bowel  below  far  more  comfortably.  If  the 
motions  have  been  allowed  to  become  constipated,  and,  in  order  to  get 
relief,  assistance  must  be  given  from  without — a  very  real  difficulty 
sometimes,  and  one  requiring  considerable  time  and  attention  on  the 
patient's  part —  this  can  be  done  ver}'  much  more  easily  with  an  anus 
in  the  iliac  region.  On  the  other  hand,  the  passage  of  flatus  or  the 
effluvium  of  a  suddenly  escaped  motion  will  be  greater  annoyances  with 
an  anus  placed  in  front.  And  it  is  obvious  that  in  some  conditions  of 
daily  life  a  lumbar  opening  may  be  very  superior  to  one  in  front.  Thus, 
at  one  time  I  watched  for  seven  years  a  case  of  lumbar  colotomy  which 
I  performed  in  a  young  married  woman,  aged  20. 

The  disadrantarjes  of  iliac  colotomij  next  recjuire  attention, 

1.  There  is  the  opening  of  the  peritona3um.  While  I  readily  allow 
that  antiseptic  details,  faithfully  followed,  have  gone  far  to  remove  the 
old  dread  of  the  peritonaeum,  there  is  no  doubt  that  a  general  adoption 
of  iliac  colotomy,  with  its  necessary  opening  of  the  peritonaeum,  in  all 
cases  and  by  all  operators,  will  add  to  the  risk  of  the  operation,  especially 
when  the  bowel  is  distended  and  fascal  extravasation  most  difficult  to 
guard  against.  The  point  is  also  alluded  to,  pp.  97,  107.  The  con- 
dition of  our  patients  before  colotomy,  too  often  low  and  poor  in  repair, 
and  the  readiness  with  which  a  little  peritonitis,  ultimately  fatal,  may  be 
excited,  must  not  be  forgotten  here. 

2.  A  much  larger  amount  of  prolapsus  follows  this  than  the  lumbar 
operation.  Of  this  there  can  be  no  doubt  whatever.  It  must  be  so,  on 
anatomical  grounds,  viz.,  the  far  greater  mobility  of  the  sigmoid  colon, 
the  greater  laxity  of  the  soft  parts  in  the  groin,  as  compared  with  those 
in  the  loin,  where  we  have  the  lumbar  fascia,  psoas,  and  kidney.  These 
points,  together  with  the  fact  that  in  walking,  standing,  and  sitting* 
the  small  intestines  must  necessarily  tend  to  push  upon  and  protrude  an 

*  ■■  A  pad  and  bandage  which  is  satisfactorily  adjusted  with  the  patient  standing 

will  require  readjustment  with  the  patient  sitting I  have  been  consulted  by 

several  subjects  of  iliac  colotomy  on  this  point,  and  found  their  grievance  to  be  a  real 
one"  (Bryant,  Lanrct,  1881,  vol.  ii.  p.  1215). 


INGUINAL   COLOTOMY.  103 

inguinal  artificial  anus,  all  explain  why  prolapsus  after  inguinal  is  so 
much  more  marked  than  after  lumbar  colotomy.  This  result,  if  the 
prolapsus  be  a  large  one,  causes  great  discomfort  to  the  patient, 
the  projecting,  moist,  readily  bleeding  mass  in  the  groin  interfering 
mucli  with  cleanliness  and  locomotion.  While  tlie  precautions  given 
later  will  serve  to  diminish  the  amount  of  prolapsus,  this  will  always 
give  more  trouble  here  than  in  the  lumbar  region :  a  tendency  to 
large  prolapsus  there  is  quite  exceptional ;  with  iliac  colotomy  it  is 
the  rule.  On  the  other  hand,  it  is  fair  to  remember  that  an  artificial 
anus,  as  opposed  to  a  ftecal  fistula,  is  much  more  t^asily  secured  after 
an  iliac  colotomy. 

3.  Another  objection  to  iliac  colotomy,  and  one  which  I  thought 
would  be  found  a  real  one — that  for  disease  high  up  in  the  rectum,  or 
of  the  sigmoid  flexure,  an  iliac  opening  would  be  placed  too  near  the 
seat  of  mischief — does  not  seem  to  have  been  verified.  Rectal  cancer, 
for  which  iliac  colotomy  is  usually  performed,  very  rarely  extends  high 
enough  up  to  give  any  trouble.  If.  on  performing  the  iliac  operation, 
the  surgeon  comes  down  on  a  growth  in  the  sigmoid,  he  must  resect  it, 
or  make  an  opening  above  it,  or  perform  a  lumbar  colotomy. 

Operation. 

The  parts  having  been  duly  cleansed,  and  shaved  when  needful,  an 
incision  2  or  2j  inches  long  is  made  l^  inch  above  and  parallel  with  the 
outer  part  of  Poupart's  ligament  and  the  anterior  superior  spine.  There 
are  t\^■o  points  here  of  the  greatest  importance  from  their  bearing  on  the 
chief  drawback  of  this  operation,  prolapsus.  Mr.  Cripps  ("'  Complications 
arising  in  Inguinal  Colotomy,"  Brit.  Med.  Journ.,  Oct.  19.  1895)  finds 
that  by  making  his  opening  in  the  abdominal  wall  somewhat  higher 
than  in  his  earlier  cases,  there  is  much  less  tendency  to  protrusion.  He 
now  makes  his  '•  incision  nearly  as  high  as  the  level  of  the  umbilicus,  so 
that  the  wall  of  the  lower  part  of  the  abdomen,  where  the  pressure  is 
greatest,  is  left  intact."'  The  other  point  to  be  insisted  on  is  that,  where- 
ever  the  opening  is  made,  it  should  be  as  small  as  possible.  The  freer 
the  incision,  the  weaker  the  abdominal  wall — already  naturally  weak 
here — and  the  more  certain  is  a  large  prolapsus  to  follow.  In  an 
ordinary  case  of  iliac  colotomy  for  rectal  cancer,  the  operator  should 
endeavour  to  find  the  sigmoid  with  an  opening  admitting  one  finger  to 
explore  deeply,  if  need  be,  as  far  as  the  pelvic  brim,  and  hook  up  the 
sigmoid.  In  more  difiicult  cases  the  above  small  opening  should  be 
enlarged  at  either  end  Avith  blunt-pointed  scissors,  cutting  on  the  left 
index  finger  as  a  director.  The  layers  of  the  abdominal  wall  having 
been  divided,  and  all  ha?morrhage  arrested,  the  peritona?um  is  then 
raised,  and  slit  up  with  scissors  for  about  two-thirds  of  the  wound 
already  existing.  The  parietal  periton£eum  is  now  stitched  to  the  cut 
skin  on  either  side  by  a  few  points  of  chromic  gut  suture.  This  ensm-es 
peritoneal  surfaces  being  in  contact  when  the  colon  is  broiight  up  into 
the  wound.  This  step  has  been  criticised  as  unnecessary  and  as  likely 
to  increase  the  tendency  to  prolapsus.  As  the  bowel  will  gradually 
form  adhesions  with  the  margin  of  the  skin  wound,  the  above  precaution 
cannot  be  said  to  be  absolutely  needful ;  but  as  it  is  well,  especially  in 
the  patients  who  come  to  us  for  colotomy,  to  assure  speedy  and  firm 
union,  I  always  make  \ise  of  it.  With  regard  to  this  step  increasing  the 
tendency  to  prolapsus,  the  precautions  just  given  will  obviate  this.   While 


I04  OPERATIONS  OX  THE  ABDOMEN. 

the  above  suturing  is  going  on.  a  small  secured  sponge  should  be  placed 
in  the  wound.  Either  the  sigmoid  or  the  omentum  or  small  intestine 
may  be  seen  in  the  wound.  If  either  of  the  two  latter  present  (and  the 
omentum  may  do  so  very  persistently),  they  are  returned,  and  the  colon 
sought  for  with  the  finger.  It  is  usually  close  at  hand,  and  may  be 
recognised  by  the  scybala  which  it  contains.  In  difficult  cases  the 
bowel  will  be  found  by  searching  in  the  iliac  fossa,  tracing  up  the 
rectum,  or  finding  the  descending  colon  over  the  kidney.  It  is  well  to 
remember  that  anterior  colotomy  is  not  always  the  easy  operation,  as 
regards  finding  the  bowel,  that  it  is  represented  to  be.  Mr.  Cripps 
speaks  {loc.  supra  cit.)  of  occasionally  having  had  great  difficulty  in 
finding  the  bowel. 

In  one  case,  after  a  long  search,  be  was  unable  to  find  the  bowel;  the  nurse  being 
directed  to  give  an  injection  of  water,  the  finger  near  the  brim  of  the  pelvis  then  felt 
a  piece  of  intestine,  which  had  before  been  overlooked,  becoming  distended,  and  the 
sigmoid,  which  was  lying  almost  over  in  the  right  iliac  region,  was  thus  detected.  In 
these  cases  of  difiiculty  Mr.  Cripps  thinks  that  the  colon  will  almost  invariably  be 
found  nearer  the  middle  line  of  the  abdomen  than  where  the  operator  has  been 
searching. 

In  a  case  of  Mr.  Cooper's,  reported  by  Dr.  Pennington,  of  Chicago  (Jourti.  Avier. 
Med.  Assoc.  1893,  vol.  ii.  p.  773).  the  operator  having  failed  to  find  the  sigmoid,  water 
was  injected  into  the  rectum,  and  was  noticed  to  pass  into  the  right  iliac  fossa.  The 
opening  in  the  left  side  being  closed,  an  incision  was  made  in  the  right  inguinal 
region,  where  the  gut — presumably  the  misplaced  sigmoid — was  readily  found.  The 
patient  made  a  good  recovery. 

The  bowel  being  found,  a  loop  of  it  is  drawn  up  into  the  wound.  In 
the  next  step  the  operator  should  carefully  follow  Mr.  Cripps  (Brit.  Med. 
Joum.,  1889,  vol.  i.  771).  To  avoid  the  prolapse  which  is  certain  to 
occur  if  loose  folds  of  the  sigmoid  remain  immediately  above  the  open- 
ing, this  surgeon  gently  draws  out  as  much  loose  bowel  as  will  readily 
come,  passing  it  in  again  at  the  lower  angle  as  it  is  drawn  out  from 
above.  In  this  way,  after  an  amount  varying  from  one  to  several  inches 
has  been  passed  through  the  fingers,  no  more  will  come.  As  soon  as 
the  descending  colon  is  found  in  this  way  to  be  nearly  taut,  a  pair  of 
dressing-forceps  is  pushed  through  the  meso-sigmoid  about  a  quarter  of 
an  inch  from  its  attachment  to  the  bowel,  and  a  straight  piece  of 
catheter  No.  10  or  12,  or  bougie,  four  inches  long  and  quite  clean,  is 
caught  in  the  forceps  and  drawn  through.  This  is  then  supported 
outside  the  abdominal  wall  at  either  end  by  antiseptic  gauze.  If  the 
meso-sigmoid  is  thick  and  laden  with  fat,  a  nick  may  be  made  over 
the  forceps  and  rod,  any  vessel  being,  of  course,  avoided.  Some  green 
protective  and  iodoform  gauze  wrung  out  of  carbolic-acid  lotion  should 
be  then  applied  over  the  bowel,  and  firm  pressure  maintained.*  The 
liowel  may  be  opened  by  a  transverse  incision  on  the  third  or  fifth  day.'t 
Ko  anesthetic  need  be  given ;  if  the  patient  is  nervous,  a  20  per  cent, 
solution  of  cocaine  niaj'  be  applied.  A  few  days  later  all  the  bowel  that 
projects  above  the  skin  is  cut  away  with  scissors,  Spencer  Wells's  forceps 
leing  applied  to  each  bleeding  point. 

*  This  is  especially  needed  during  the  first  few  days.  Mr.  Cripps  insists  on  the 
nurse  sitting  by  the  bedside  to  apply  pressure  if  vomiting  occurs. 

t  Vomiting  and  distension  of  the  abdomen  are  other  indications  for  opening  the 
bowel  earlv. 


INGUINAL  COLOTOMY.  105 

All  sutures  should  be  removed  b}'  the  tenth  day,  or  earlier  if  any 
redness  is  present. 

Mr,  H.  Allingham  (Brit.  Med.  Journ.,  1892.  vol.  i.  p.  1013)  believes 
that  the  above  method,  while  preventing  prolapse  from  the  upper  end, 
will  not  prevent  its  taking  place  from  the  lower  when  the  mesentery'  is 
long.  He  accordingly,  instead  of  pulling  out  the  sigmoid  until  it  is 
tight  at  its  upper  end  only,  pulls  the  bowel  out  until  it  is  tight  at  the 
upper  and  lower  ends  alike,  a  step  involving  the  withdrau-ing  and 
heaping  up  outside  the  abdomen  many  inches  of  intestine  when  the 
mesentery  is  long.  To  keep  the  loop  in  situ  a  stitch  is  put  through  the 
skin  on  one  side,  then  through  the  mesentery  behind  the  bowel,  back 
again  through  the  mesentery,  and  then  tied  to  the  end  of  the  suture 
which  has  passed  through  the  skin.  When  this  is  tightened,  the 
peritoneum  of  the  meso-colon  is  kept  pressed  against  the  parietal 
peritongeum.  and  quickly  adheres.  The  gut  is  also  fixed  to  the  edges  of 
the  wound  in  the  ordinary  way,  and  opened  about  the  third  day.  After 
about  a  week  ^[v.  Allingham  cuts  away  all  the  projecting  intestine, 
sometimes  removing  as  much  as  a  foot,  a  clamp  being  first  applied  close 
to  the  skin,  while  all  above  the  clamp  is  cut  away.  The  clamp  is  left  on 
for  twenty-four  hours.  As  inguinal  colotomy  is  chiefly  performed  for 
rectal  cancer,  this  method,  as  I  wrote  in  a  former  edition,  appears  to  me 
to  be  needlessly  severe.  The  kind  of  patients  with  whom  the  surgeon 
is  now  usually  dealing  must  never  be  lost  sight  of.  They  are  too  often 
the  subjects  of  a  mortal  disease,  M-ith  no  very  long  tenure  of  life  before 
them,  pulled  down  in  strength  and  feeble  in  repair.  Sir  F.  Treves  also 
condemns  the  above  method  very  strongly.  "  There  is  nothing  to 
recommend  this  mutilation,  and  most  surgeons  will  join  with  Mr. 
Bryant  and  others  in  their  condemnation  of  this  uncouth  proceeding" 
{Operative  Surf/ert/,  vol.  ii.  p.  375). 

In  his  later  papers  Mr.  Allingham  admitted  the  severity  of  this  pro- 
ceeding for  cases  of  cancer,  and  now  reserves  it  for  "  cases  of  simple 
stricture  where  patients  might  live  for  years." 

Mr.  Cripps's  far  simpler  and  milder  method  described  above — pulling 
out  as  much  loose  sigmoid  as  will  easily  come,  returning  the  slack  at 
the  lower  end  of  the  wound  as  it  is  drawn  out  from  the  upper,  and 
fixing  in  the  wound  a  good  loop  of  the  part  which  is  found  to  be  tight 
— will  be  found  amply  sufficient.  When  the  projecting  loop  has  been 
pared  down,  as  advised  above,  two  openings  will  be  seen  separated  by 
an  efficient  spur.  Through  the  lower  of  these  the  rectum  can  be  washed 
out,  and  the  removal  of  any  fJEeces  lying  above  the  disease  facilitated. 
Gradually,  usually  in  about  a  month,  the  patients  will  begin  to  acquire 
some  control  over  their  artificial  opening,  but  it  will  not  be  till  several 
months  after  the  operation  that  they  can  be  said  to  become  comfortable 
in  this  respect,  and  acquire  satisfactory  control  over,  and  management 
of,  their  artificial  anus.  And  for  the  rest  of  their  life  discharge  of  blood 
and  slime  will  occur  from  the  anus  with  frequency,  var^'ing  according 
to  the  rate  of  growth  of  the  original  disease.  This  must  be  met  by 
astringent  injections  and  suppositories.  Diarrhoea  must  be  ti-eated 
by  strict  attention  to  diet,  and  by  astringents ;  escape  of  offensive 
flatus  or  fasces  from  the  artificial  anus  (which  is  more  perceptible  to 
the  patient  when  the  opening  is  made  in  front)  ma}'  be  met  by  the 
use  of  charcoal,  a  teaspoonfnl  being  given  twice  a  day,  or  the  following 


I06  OPERATIONS  OX  THE  ABDOMEN. 

may  be  taken  twice  a  day  in  a  capsule  or  cachet,  viz.,  betol,  salol, 
salicylate  of  bismuth,  of  each  gr.  v.  (Mr.  C.  Heath,  Brit.  Med.  Journ., 
vol.  i.  1892.  p.  1243). 

Where  obstruction  is  present,  the  bowels  much  distended,  and  the 
sigmoid  requires  immediate  opening,  anterior  colotomy  may  still  be 
employed,  but  additional  care  must  be  taken  in  handling  the  intestines 
and  in  preventing  any  escape  of  ffecal  fluid  or  gas  into  the  peritoneeal 
cavity. 

The  following  methods  may  be  adopted : 

Extra  pains  having  been  taken  to  suture  the  bowel  accurately  to 
the  edges  of  the  wound,  the  distended  gut  is  incised,  and  the  fteces 
as  they  flood  the  wound  are  washed  away  by  a  stream  of  warm  water^ 
which  is  kept  constantly  pouring  over  the  wound  for  ten  minutes  until 
the  distension  is  relieved.  The  wound  is  then  most  carefully  scrutinised 
and  washed,  and  the  dressings  applied  (Cripps). 

Mr.  Barker  (Man.  of  Surg.  Oper.,  p.  309)  advises  that  the  distended 
intestine  should  be  opened  with  a  fine  trocar.  On  withdrawing  the 
cannula  the  puncture  is  at  once  closed  by  mucous  membrane.  In  one 
case  Mr.  Barker  drew  off  the  fluid  through  a  temporarj^  puncture  for 
several  days  before  a  permanent  opening  was  established.  The  patient 
made  an  excellent  recovery. 

The  objection  to  this  method  is  that  where  distension  is  urgent  it 
will  be  difficult  to  give  sufficient  relief  by  a  trocar  which  is  of  sitch 
small  bore  that  a  puncture  by  it  will  be  safe. 

A  rubber  drainage-tube  of  large  diameter  may  be  fixed  in  the 
bowel,  as  suggested  by  Greig  Smith.  This  will  be  described  under 
Enterostomy. 

Mr.  Mayo  Robson  has  modified  Mr.  Barker's  plan  on  two  occasions  with 
success  by  puncturing  the  bowel,  already  stitched  to  the  side,  with  a 
large  trocar  and  cannula,  then  fixing  india-rubber  tubing  on  to  the 
cannula,  so  that  the  liquid  faeces  may  be  conveyed  into  an  antiseptic 
solution  by  the  bedside,  thus  preventing  fouling  of  the  peritonaeum 
or  wound. 

To  save  the  trouble  of  fixing  the  tubing  on  to  the  cannula  when 
in  the  bowel,  Mr.  Robson  has  fixed  the  tubing  on  the  cannula  first, 
and  then  pushed  the  trocar  through  it.  When  the  trocar  is  withdrawn, 
the  slit  in  the  tubing  immediately  closes,  and  prevents  anything  passing 
through  it.  This  has  led  Mr.  Robson  to  recommend  a  trocar  with  a 
small  lateral  limb  attached,  to  allow  a  tube  to  be  fixed  on  it  to  convey 
the  faeces  away  from  the  wound.  The  end  of  the  cannula  within  the 
boA\"el  is  rounded  off  so  as  to  avoid  a  sharp  edge ;  to  the  other  end 
a  short  piece  of  tubing  is  attached  which  embraces  the  trocar,  and 
is  securely  closed  by  a  ligature  as  soon  as  the  trocar  is  with- 
drawn. Nothing  is  said  about  any  difficulty  in  retaining  such  a 
cannula  in  the  bowel ;  it  is  merely  stated  that  it  may  be  held  in 
position  for  the  needftil  two  or  three  days  by  strapping  applied  over 
an  ordinar}' antiseptic  dressing  (^r;")'.  Med.  Journ.,  vol.  i.  1892,  p.  65). 

A  Paul's  tube  ma}^  be  tied  in  (Fig.  39).  The  objection  which  has 
been  raised  to  the  method,  namely  that  sloughing  and  loosening  of 
the  tube  take  place  too  rapidly,  may  be  met  by  making  use  of  a 
purse-string  suture  to  fix  the  tube,  and  by  taking  care  not  to  tie  the 
ligature  tighter  than  is  absolutely  necessar3^     See  also  Enterostomy. 


INGUINAL  COLOTOMY.  107 

I    would    strongly    impress    on    my    younger    readers   the  need   of 
careful  attention  to  the    following  points  when    dealing  with   chronic 
obstruction    low  clown   in    the    large    intestine    by   inguinal    colotoniy. 
First,  the  sigmoid  is  difficult  to  find,  owing  to 
the  tendency  of  the  small  intestine,  much    dis-  Fic  39. 

tended,  to  crowd  out  of  the  wound.  It  is  very 
easy,  during  the  necessary  handling  of  such  intes- 
tine, to  make  small  tears  in  the  peritonteal  coat. 
In  meeting  the  above  difficulty  the  operator,  if 
he  cannot  find  the  sigmoid  quickly,  should  en- 
large the  wound  and  pack  away  the  small  intes- 
tine with  flat  sponges  attached  to  forceps.  The 
second  point  is  the  great  care  needed  in  suturing 
a  distended  sigmoid  when  it  is  brought  to  the 

lips  of  the   wound,   it  being  now    verv  easv  to  ^-^     •  ^     *i    1        ^ 

^  1     1         "  "^  A o.  I  IS  for  the  large,  ^\o. 

perforate    the   mucous  coat,   and  thus  cause    an      lor  the  small,  iutestiue. 
escape  of  flatus  or  faeces  before  the    peritona?al      jjig  lower  end   is  tied 

sac  13    shut    on^.  in,  the  upper  receives  the 

Madelung's  Modification  of  Colotomy. — This  drainage-tube.    (Paul.) 
has  been  largely  used,  both   in  the  lumbar  and 

inguinal  operation,  abroad.  In  this  country  it  has  not  found 
favour.  It  consists  in  drawing  out  the  bowel  sufficientl}*,  packing 
the  wound  "^^'ith  small  sponges  attached  to  silk,  while  the  loop  of 
intestine  (which,  if  full,  should  be  emptied  as  far  as  possible  by 
squeezing  its  contents  upwards)  is  packed  around  with  tampons  of 
iodoform  gauze.  The  intestine  being  clamped,  or  held  by  the  fingers 
of  assistants,  is  next  cut  across.  The  clamp  is  then  removed  from  the 
lower  end,  which  is  emptied,  cleansed,  and  closed  by  careful  suturing, 
viz.,  one  continuous,  and  then  others  by  Lembert's  method,  causing 
efficient  inversion  of  the  sutured  extremity.  This  end  is  then  dropped 
back  into  the  peritonteal  cavity.  Tlie  upper  end  is  now  fixed  in  the 
wound,  or  is  drained  by  tying  a  glass  tube  in  it  to  which  india-rubber 
is  attached,  by  the  method  of  Mr.  Paul  (Fig.  39)  (Brit.  MeJ.  Joimi., 
vol.  ii.  1 89 1,  p.  118). 

The  above  method  has  never  been  much  used  in  this  country,  for 
the  following  reasons  : — 

1.  The  great  advantage  which  it  claims,  of  preventing  the  passage 
of  ffeces  into  the  lower  part  of  the  bowel,  may  be  secured  by  much 
simpler  means,  viz..  pulling  out  the  bowel  sufficiently  to  get  an  efficient 
spur,  and  cutting  away  the  intestine  afterwards. 

2.  It  has  inherent  grave  objections : — 

(a)  It  has  happened  again  and  again  that  when  the  mesenteiy  is 
long  the  sigmoid  has.  unknown  to  the  operator,  become  twisted,  and 
thus,  Avhen  it  is  drawn  up  into  the  wound,  the  upper  instead  of  the 
lower  end  may  be  closed  and  returned.  In  such  a  case  fa?cal  extra- 
vasation through  the  sutures  into  the  peritona^al  cavity  must  occur. 
Mr.  H.  Allingham  states  (Brit.  Med.  Jonrn.,  1891,  vol.  ii.  p.  337)  that  in 
seven  of  his  inguinal  colotomies  the  gut  must  have  been  thus  ""twisted, 
as  faeces  came  away  through  the  lower  of  the  two  openings.  He  states 
that  he  knows  of  a  fatal  termination  from  this  cause  in  several  cases 
in  which  Madelung's  operation  had  been  adopted.  Mr.  Cripps  {ilnd., 
p.  447)  has  met  with  two  cases  in  which  what  he  believed  to  be  the 


I08  OPERATIONS  OX  THE  ABDO:\IEX. 

lower  end  of  the  bowel  eventually  proved  to  be  the  upper.  Dr.  Landon, 
of  C4ottingen  (Centr.  f.  Chir.,  Bd.  xxx.,  1891)  has  explained  the  above 
fact  by  a  necropsy. 

lu  two  cases  of  inguinal  colotomr  in  the  Gottingen  clinic,  where  the  usual  practice 
is  to  divide  the  gut  and  to  stitch  the  two  open  ends  in  the  wound,  it  was  noticed  that 
fseces  always  discharged  from  the  lower  and  not  from  the  upper  opening,  although 
at  the  operation  the  lower  part  of  the  intestine  had  been  traced  towards  the  bladder, 
and  the  upper  in  the  reverse  direction.  In  one  of  these  cases,  which  terminated 
fatally,  the  necropsy  showed  that  the  sigmoid,  which  was  very  long  and  freely  movable, 
passed  upwards  and  outwards  as  far  as  the  splenic  flexure  of  the  colon,  and  then 
curved  downwards  and  towards  the  middle  line,  reaching  the  rectum  after  a  long 
and  tortuous  course. 

(h)  The  lower  end  of  the  bowel,  whatever  precautions  are  taken 
before  the  operation,  will  contain  some  faeces  above  the  site  of  the 
cancer  :  if  the  lower  end  of  the  bowel  be  sutured,  these  feeces  must  cause 
irritation  and  increased  discharge  ;  if  the}*  be  scybalous,  and  the  bowel 
above  the  stricture  thinned,  as  it  often  is,  they  may  bring  about  fatal 
ulceration,  (c)  Closing  the  lower  end  prevents  an}*  attemi^t  at  washing 
out  the  bowel  by  syringing  through  from  the  colotomy  opening  to  the 
anus  or  vice  versa,  and  so  diminishing  the  constant  tendency  to  sanious 
mucous  discharge,  which,  if  left  to  collect  above  the  cancer,  hastens  its 
giowth  and  promotes  its  sloughing,  (d)  It  adds  to  the  severit}'  of  an 
operation  in  patients  who.  from  their  present  and  in  view  of  their 
future,  need  careful  handling.  This  is  true  of  inguinal  colotomies 
when  the  bowel  is  empty.  If  it  be  distended,  severing  the  bowel 
adds  greatly  to  the  difficulties  of  what  is  now  a  trying  operation,  and 
increases  the  risks  of  contamination  of  the  peritonaeum. 

This  modification  of  Madelung"s  is,  I  think,  only  justifiable  when 
colotomy  is  performed  previously  to  removal  of  part  of  the  rectum : 
even  under  these  circumstances  I  think  it  may  be  harmful,  by  pre- 
venting the  washing  out  of  the  intervening  bowel  which  may  add 
so  much  to  the  comfort  of  the  patient.  Any  surgeon  about  to  divide 
the  bowel  should  make  certain  of  the  lower  end  b}-  asking  an  assistant 
to  pass  from  below,  if  possible,  a  small  oesophagus-bougie. 

If  the  artificial  anus  contract  unduly,  it  must  be  dilated  with  lami- 
naria  tents  and  the  i)atient's  finger.  Mr.  Cripps  has  introduced  a  spring 
dilator  which  is  self-retaining,  and  which  can  be  worn  for  four  or  five 
hours  daih".  That  this  complication  is  one  to  be  watched  for  is 
plain  from  this  passage  in  Mr.  Cripps's  experience  (Brit.  Med.  Journ., 
vol.  ii.  1895.  P-  966):  '"This  is  not  an  uncommon  sequence,  and,  if 
allowed,  will  destroy  the  whole  advantage  of  the  operation.  Too  small 
an  opening  means  a  constant  dribbling  of  ffecal  matter,  the  motions 
never  getting  freely  and  completely  away.  These  contractions  do  not 
occur  where  the  original  opening  has  been  made  of  jiroper  size,  and 
where  all  the  woitnd  has  healed  by  first  intention,  but  occur  where  the 
angles  of  the  A\'ound  have  failed  primarily  to  unite,  and  where  the 
granulations  gradually  become  converted  into  firm  contractile  tissue.  If 
the  angles  have  not  united  properly,  the  contraction  will  begin  about 
the  third  week:  and  if  at  this  time  a  little  spring  dilator  be  introduced 
and  worn  for  a  feA\'  hours  daily  for  a  month,  the  tendenc}^  to  undue 
contraction  will  Ije  obviated.  If  this  precaution  has  been  neglected, 
or  be  impracticable,  the  opening  can  readily  be  made  the  right  size 


IXGUIXAL  COLOTOMY. 


109 


by  passing  the  finger  into  tlie  bowel,  and  then  completely  cutting- 
through  all  the  contractile  tissue  up  to  each  angle,  the  depth  of  the 
cut  exposing  the  wall  of  the  bowel.  The  bowel  is  now  freed  a  little 
on  either  side  of  the  incision,  and  a  curved  needle  and  silk  thread  is 
passed  through  its  edge,  and  through  the  tissues  and  skin  at  the  apex 
of  the  reopened  wound.  This  suture  is  tied,  bringing  the  gut  well  up 
to  the  angle.  A  couple  of  additional  sutures  may  be  necessary  at  the 
sides." 

Mr.  Cripps  considers  that  nothing  in  the  way  of  a  plug  or  truss 
answers  so  well  as  a  dressing  of  lint  smeared  with  some  simple  oint- 
ment, covered  with  a  large  flat  pad  of  cotton-wool,  the  whole  being 
kept  in  position  by  a  wide  flannel  bandage,  a  perinaeal  strap  being  used 
if  needful.  If  a  plug  is  desired,  one  of  the  most  comfortable  is  an 
india-rubber  one.  which  can  be  introduced  collapsed  and  then  inflated 
by  the  patient.  The  chief  drawback  to  this  in  hospital  patients  is  that 
the  india-rubber  requires  frequent  renewal. 

On  the  whole,  I  prefer  a  pad  supported  by  a  light  spring  truss  to 
check  any  escape  of  flatus,  &c.  Its  use  should  be  begun  early,  to  give 
support  and  check  prolapsus. 

Complications  and.  Di£B.culties  in  Inguinal  Colotomy. — Many  of 
those  given  at  p.  98  are  common  to  the  inguinal  and  lumbar  operations. 
Some  more  specially  belonging  to  the  former  operation  will  be  given 
here. 

I.  Difficulty  in  finding  the  bowel.  This  has  been  fully  entered  into 
at  p.  104.  It  is  well  to  remember  that  the  claim  so  strongly  put 
forward,  that  the  inguinal  is  an  operation  of  no  difficulty  as  compared 
with  the  lumbar,  is  not  always  correct.  2.  Absence  or  shortness 
of  mesentery.  I  will  here  quote  Mr.  Cripps  (Brit.  Med.  Journ., 
vol.  ii.  1895,  p.  966):  "This  is  perhaps  the  most  unfortunate  and 
dangerous  complication  that  can  be  met  with,  and  to  this  cause,  with 
one  exception,  I  owe  all  my  fatal  cases.  In  the  great  majority 
of  cases  the  mesentery  of  the  sigmoid  flexure  is  amply  sufficient 
to  allow  of  the  bowel  being  well  drawn  up  in  the  wound,  and 
safely  fixed  without  tension  ;  but  in  3  or  4  per  cent,  this  is  not  so. 
tor  there  is  absolutely  no  mesentery,  the  bowel  being  bound  firmly 
back  against  the  posterior  parietes.  This  is  either  due  to  congenital 
deficiency,  or  to  malignant  disease  behind  the  colon  fixing  it  firmly. 
The  question  to  be  considered  is  as  to  what  should  be  done  after  the 
surgeon  has  opened  the  abdomen  and  met  with  one  of  these  cases.  I 
am  confident,  from  my  unfortunate  experience,  that  any  endeavour  to 
invert  the  skin  and  forcibly  drag  it  down  to  the  bowel  by  the  sutures 
is  a  fatal  mistake.  The  sutures  will  certainly  cut  through,  leaving  an 
open  peritonasal  cavity.  The  surgeon  has  three  choices  :  he  may  either 
abandon  the  operation  altogether,  he  may  close  the  abdominal  wound 
on  the  left  side  and  perform  a  colotomy  on  the  right  side,  or  he  may 
endeavour  by  some  modification  of  the  usual  operation  to  fix  the  bowel 
without  dangerous  tension.  If  he  abandons  the  operation  altogether  I 
do  not  consider  he  is  to  be  blamed,  but  most  surgeons  would  prefer  to 
close  the  wound  and  open  the  c?ecum  or  ascending  colon.  Although  the 
subsequent  inconvenience  of  a  right  colotomy  is  far  greater  than  the 
left,  on  account  of  the  less  solid  nature  of  the  fteces.  nevertheless  it 
fulfils  the  chief  purpose  for  which  colotomy  was  undertaken,  namely,  the 


no  OPERATIONS  ON  THE  ABDOMEN. 

establishment  of  a  permanent  safety-valve  against  death  from  obstruc- 
tion. If  the  colon  is  absolutely  fixed  and  lying  at  some  depth  from  the 
parietal  peritonasura,  this  is  the  course  I  would  advocate.  If  the  bowel 
is  not  absolutely  fixed,  it  may  be  possible  by  means  of  a  Hagedorn's 
needle  to  suture  the  parietal  peritonaeum  to  the  sides  of  the  bowel, 
leaving  sufficient  space  between  the  two  layers  for  the  opening.  No 
attempt  \\'hatever  must  be  made  to  draw  the  parietal  peritonasum  and 
the  skin  together,  the  skin  and  all  the  structures  above  the  peritoneum 
being  excluded  from  the  sutures.  By  merely  attaching  the  peritonteum 
in  this  way,  the  tension  on  the  sutures  is  materially  diminished.  By 
opening  the  bowel  opposite  to  the  mesenteric  attachment,  and  then 
fixing  the  cut  edges  to  the  parietal  peritonaeum,  the  tension  on  the 
sutures  is  further  diminished.  In  any  case,  if  the  bowel  has  been  fixed 
with  the  least  tension,  the  jDatient  must  be  carefully  watched  from  day 
to  day,  and  on  the  least  sign  of  the  bowel  falling  back,  additional 
salmon-gut  sutures  should  be  at  once  passed  through  the  whole  thick- 
ness of  the  edges  of  the  bowel  and  the  abdominal  walls."  I  would 
suggest  another  means  of  meeting  this  difficulty,  which  I  adopted  in 
the  only  case  that  I  have  met  with  in  which  the  sigmoid  was  abso- 
lutely tied  down  in  the  iliac  fossa,  apparently  from  a  congenital  absence 
of  the  mesentery.  The  lower  part  of  the  incision  being  closed,  its  upper 
extremity  was  prolonged  backA\'ards  into  the  lumbar  region,  where,  at  the 
junction  of  the  descending  and  sigmoid  colons,  the  bowel  was  sufficiently 
mobile  to  be  brought  up  into  the  wound.  This  course  will,  I  believe, 
al\va}'s  be  found  feasible.  It  is  preferable  to  performing  a  right 
colotomy,  as  it  saves  two  wounds,  and  rolling  the  patient  over  on  to  a 
recently  made  wound,  while  it  removes  an  objection  inseparable  from  a 
right-sided  colotomy,  that  a  more  or  less  extensive  tract  of  bowel  is  left 
below  the  opening,  containing  fgeces  which  it  is  not  easy  to  get  rid  of. 
3.  Prolapsus.  The  frequency  of  this  after  the  operation  has  been 
explained  at  p.  102.  It  may  be  met  (a)  by  making  the  wound  as  high 
up  as  possible  (p.  103);  (/>)  drawing  down  the  intestine  till  the  upper 
end  is  tight  (Cripps).  and  then  bringing  it  out  through  as  small  an 
opening  as  possible ;  (c)  closing  this  opening  round  the  bowel,  and  the 
bowel  to  the  edges  of  the  wound,  as  securely  as  possible,  whether  a  rod 
(p.  104)  has  been  used  or  no;  (d)  keeping  the  patient  at  rest  until 
the  parts  have  had  full  time  to  consolidate ;  (e)  treating  assiduously 
any  such  causes  as  constipation,  coughing,  straining  in  micturition,  &c. ; 
(/)  trying  the  effect,  as  early  as  may  be,  of  a  light  spring  truss  and 
pad.  The  two  following  complications  may  occur  during  vomiting  or 
coughing.  4.  Small  intestine  or  omentum  may  escape  between  the 
piece  of  sigmoid  which  has  been  drawn  out  and  the  edges  of  the  wound. 
This  accident  may  be  known  by  the  urgent  vomiting,  pain,  collapse,  and 
,soakage  of  serum  into  the  dressings.  These  should  of  course  be  removed 
at  once,  the  small  intestine  cleansed  and  returned,  and  the  wound  made 
safe  by  additional  sutures.  This  accident  is  most  likely  to  occur  when 
a  large  wound  has  been  made,  an  insufficient  number  of  sutures  used, 
and  the  nurse  has  not  made  efficient  pressure  with  her  hand  over  the 
dressings  (p.  104).  Where  omentum  protrudes — a  much  rarer  compli- 
cation— it  may  be  left,  as  it  will  all  shrivel  away  gradually,  but 
additional  sutures  should  be  inserted  at  once.  5.  A  rarer  accident,  of 
u'hich  Mr.  Cripps  has  published  an  instance  (Brit.  Med.  Journ.,  vol.  ii. 


INGUINAL  COLOTOMY.  Ill 

1895,  P-  967),  is  where  the  bowel  tears  away  from  its  attacliments  and 
falls  back  into  the  peritoneal  cavity.  This  happened  on  the  seventh 
da}^  daring  a  violent  fit  of  coughing. 

"  The  released  bowel  discharged  a  considerable  motion  into  the  peritonieal  cavity. 
FortunatelT,  I  saw  the  case  about  an  hour  after  the  accident.  The  fjecal  matter  was 
thoroughly  washed  out  from  the  abdomen,  and  the  detached  bowel  restitched.  The 
patient  recovered."* 

6.  Strangulation  of  small  intestine  between  the  attached  sigmoid  and 
the  parietes.  An  instance  of  this  very  rare  accident  will  be  found 
recorded  by  Mr.  Cripps  {loc  sa[tra  cit.,  p.  967). 

A  patient  on  whom  inguinal  colotomy  had  been  performed  was  about  to  leave  the 
hospital  when  he  was  seized  with  symptoms  of  acute  obstruction,  the  pain  being 
referred  to  the  colotomy  opening.  After  vomiting  three  or  four  times  the  patient  said 
he  felt  something  slip  in  his  inside  ;  the  vomiting  ceased,  and  the  pain  suddenly  left 
him.  A  few  days  after,  feeling  quite  well,  he  was  discharged  from  the  hospital,  and 
was  re-admitted  ten  days  afterwards  in  a  dying  condition.  The  necropsy  showed  that 
a  loop  of  small  intestine  had  slipped  down  into  a  canal,  about  an  inch  long,  between 
the  attached  portion  of  the  gut  and  the  reflection  of  the  parietal  peritonaeum,  near  the 
anterior  superior  spine.  From  this  canal  the  intestine  must  have  released  itself  at 
the  first  attack.  Mr.  Cripps  adds  that  prompt  abdominal  section  would  have  saved 
this  patient. 

Causes  of  Death  after  Anterior  Colotomy. — Many  of  these  will  be 
the  same  as  those  given  in  the  account  of  the  lumbar  operation  (p.  lOO), 
and  others,  more  peculiar  to  the  anterior  operation,  have  been  so  fully 
given  in  the  pages  just  preceding  that  there  is  no  need  to  repeat  them 
here. 


RIGHT    INGUINAL    COLOTOMY. 
MAKING    AN    ARTIFICIAL    ANUS    IN    THE    C^CUM. 

This  operation  is  but  rarely  made  use  of.  One  objection  to  it  is  that, 
owing  to  the  proximit}'  of  the  small  intestines,  the  intestinal  contents 
are  likely  to  be  more  liquid,  and  thus  to  cause  more  trouble  afterwards. 
It  may  be  resorted  to  under  such  conditions  as  the  following  : 

1 .  When,  in  chronic  obstruction  of  the  large  intestine,  the  site  of  the 
mischief  is  uncertain  and  the  cgecum  is  much  distended.  Here,  owing  to 
the  tendency  of  the  caecum  to  slough  from  over-distension,  a  surgeon 
would  be  quite  justified  in  cutting  down  upon  the  caecum  instead  of 
resorting  to  right  lumbar  colotomy,  if  he  felt  sure  of  being  able  to 
prevent  contamination  of  the  peritoneal  cavity  from  the  escaping  faeces. 

2.  When,  during  the  performance  of  a  right  lumbar  colotomy,  finding 
the  colon  is  impossible. 

In  the  above  instances  the  caecum  would  be  reached  by  an  incision 
made  over  it.  And,  personally,  when  the  surgeon  has  been  exploring 
the  site  of  an  obstruction  through  the  linea  alba  and  determines  to 
open  the  cecum,  I  think  it  would  be  wise  to  do  this  through  a  second 

*  Mr.  C.  Heath's  remarks  on  this  or  a  similar  case  QBrit.  Med.  Joitrn..  vol.  i.  1892. 
p.  1243)  are  worth  the  attention  of  anyone  inclined  to  think  lightly  of  such  an 
accident  because  the  patient  recovered.  "  Of  course  we  hear  of  one  case  that  did 
recover,  but  we  do  not  hear  of  the  ninety-and-niue  cases  which  did  not."  The  remarks 
which  follow  on  the  value  of  statistics  are  too  bitter  for  me  to  insert  them  liere,  but 
they  contain  a  very  large  germ  of  truth. 


112  OPERATIOXS  OX  TILE  ABDOMEN. 

incision  in  the  right  iliac  region,  as  I  consider  it  risk}-  to  anchor 
intestine  in  the  middle  line. 

Sir  F.  Treves  (Lancet,  vol.  ii.  1887,  p.  853)  published  a  very  successful 
case,  in  which  exploration  in  the  middle  line  detected  a  stricture  at  the 
termination  of  the  descending  colon.  As  the  Ciecum  was  enormously 
distended,  its  peritonjeal  coat  having  given  way  at  several  spots,  he 
brought  the  ca3cum  into  the  Avound  in  the  linea  alba,  bringing  all  the 
most  damaged  part  out  of  the  wound,  which  was  united  round  it. 
A  puncture  of  the  caecum  through  one  of  the  rents  allowed  an  immense 
amount  of  gas  to  escape.  Fortunately  no  feeces  were  seen.  The  hole 
in  the  bowel  was  clamped,  and  the  wound  dressed  with  iodoform. 
When  the  bowel  was  opened  on  the  fifth  da}-  a  large  quantity  of  frecal 
matter  escaped.     Six  months  later  the  patient  was  in  excellent  health. 

On  the  other  hand,  the  case  of  Mr.  Cripps,  which  I  quoted  at  p.  in, 
shows  how  very  small  a  space  between  anchored  bowel  and  the  parietes 
may  be  sufficient  to  bring  about  a  fatal  strangulation. 

Operation. 

This  differs  so  slightly  from  a  left-sided  iliac  colotomy  that  very  little 
more  need  be  said. 

The  incision  should  be  about  three  inches  long  over  the  distended 
intestine,  or  parallel  with  the  outer  part  of  Poupart's  ligament  and 
the  iliac  crest.  There  may  be  no  meso-cascum  ;  in  such  a  case  the 
surgeon  may  experience  considerable  difficulty  in  getting  the  ceecum 
satisfactorily  into  the  wound. 

MAKING    AN    ARTIFICIAL    ANUS    IN    THE    TRANSVERSE 

COLON. 

This  is  the  most  rarely  performed  of  all  the  colotomies.  Mr.  H. 
Allingham  gives  three  cases  in  his  book  on  Colotomy,  p.  170 — one 
of  his  own,  and  two  performed  at  St.  George's  Hospital. 

lu  oue,  chronic  obstruction  was  present,  and  a  median  incision  showed  a  growth 
in  the  descending  colon.  The  lower  part  of  the  exploring  incision  having  been 
closed,  in  the  upper  two  inches  the  parietal  peritoneum  was  stitched  to  the  skin  ; 
the  transverse  colon  was  brought  out  here  and  stitched  in  the  iisual  way.  The 
bowel  was  opened  the  next  day.  In  another  case,  opening  the  transverse  colon  was 
preferred  to  lumbar  colotomy,  on  account  of  the  diflBculty  of  making  a  satisfactory 
spur  in  the  latter  position. 


CHAPTER   IV. 
OPERATIONS  ON  THE  KIDNEY  AND  URETER. 

NEPHROTOMY— NEPHRO-LITHOTOMY— NEPHRECTOMY— 
NEPHRORRAPHY— OPERATIONS  ON  THE  URETER. 

NEPHROTOMY. 

Indications. — The  following  are  the  principal  conditions  which 
demand  this  operation  : — 

i.  Pyonephrosis  and  Abscess  of  the  Kidney. — When  due  to  tuber- 
culous disease,  and  the  tumour  is  large,  or  the  patient  is  not  in  a 
condition  to  stand  primary  nephrectomy,  nephrotomy  should  be  per- 
formed as  a  preliminary  measure  ;  when,  however,  there  is  evidence 
of  disease  of  the  opposite  kidnej"  or  of  other  viscera,  nephrotomy 
alone  is  available.  The  results,  however,  when  a  secondary  nephrec- 
tomy cannot  be  performed  are,  as  might  be  expected,  extremely 
unsatisfactory.  Otto  Ramsay,  of  Baltimore  (Annals  of  Surgery,  vol.  ii. 
1900,  p.  461  et  seq.),  gives  the  results  of  fifty-five  cases.  Of  these, 
four  at  the  most,  and  probably  two  only,  can  be  considered  as  cured. 

When  the  abscess  is  due  to  calculi,  these  will  be  removed  and  the 
cavity  drained,  except  in  special  cases  where  nephrectom}''  is  indicated 
(vide  infra,  p.  1 30). 

In  a  few  rare  instances  pyonephrosis  may  be  due  to  a  sti'icture  of 
the  ureter.  An  example  of  this  condition  is  referred  to  below  under 
the  Surgery  of  the  Ureter  (vide  p.  170). 

ii.  Hydronephrosis. — If  the  kidney  has  been  entirely  destroj^ed, 
and  the  size  of  the  tumour  prevents  removal,  incision  and  drainage 
should  be  employed  either  as  a  method  of  cure  or  as  a  preliminary 
to  a  secondary  nephrectom3^ 

iii.  As  an  exploratory  operation  for  diagnostic  purposes  for  certain 
obscure  renal  symptoms.  Some  of  the  conditions  that  have  been 
found  are  mentioned  below  under  Nephro-lithotomy  (vide  p.  1 18);  in 
others  a  calculus  will  be  found.  In  others  again,  particularly  where 
the  only  symptom  is  hsematuria,  the  exploration  may  have  a  negative 
result. 

Hurry  Fenwick  (Brit.  Med.  Journ.,  vol.  i.  1900.  p.  248),  however, 
records  two  striking  cases  of  operation  for  unilateral  painless  renal 
haematuria. 

In    the    first    case,    a    young    lady,    aged    18.    had    suffered    from 

attacks  of  heematuria  for  five  years,  causing  marked  anaemia.     With 

the    cystoscope   the    blood  was  seen   to    come   from    the    left    ureter. 

At  the  operation  the  left  kidney  was  brought  out  on  to  the  loin,  the 

VOL.   II.  8 


114  OPERATIONS  ON  THE  ABDO^IEN. 

pelvis  incised  and  illuminated  with  electric  light.  It  was  then  seen 
that  one  of  the  renal  papillae  was  of  a  bright  red  colour,  and  appeared 
to  be  villous  on  the  surface.  The  papilla  and  half  the  pyramid  were 
removed  with  a  Volkmann's  spoon.  No  hjematuria  has  occurred  since 
the  operation. 

In  the  second  case  there  had  been  alarming  hematuria  for  a  fort- 
night, producing  profound  antemia.  The  blood  was  seen  to  come 
from  the  left  ureter.  The  operation  was  similar  to  that  performed  in 
the  first  case,  as  was  also  the  condition  found.  This  case  was  like- 
wise completely  cured. 

iv.  Anuria. — This  will  be  dealt  with  later  (ride  p.  137). 

Operation, — As  this  is  identical  with  the  first  stages  of  a  nephro- 
lithotomy the  reader  is  referred  to  the  description  of  that  operation 
(vide  p.  123). 

NEPHRO-LITHOTOMY. 

The  following  are  the  chief  symptoms  and  conditions  justifying 
nephro-lithotomy  : — 

I.  Continued  Hcemahtria,  or  Passcuje  of  Blood  and  Pus. — I  may  at 
once  be  criticised  for  putting  this  first;  and,  indeed,  it  is  somewhat 
difficult  to  decide  which  symptom  of  renal  calculus  is  clinically 
the  most  important.*  On  the  whole,  I  am  inclined  to  agree  with 
an  old  friend,  G.  A.  Wright,  of  Manchester  (Med.  Ghron.,  March 
1887,  p.  463),  who  considers  "renal  hsematuria  as  the  only  single 
symptom  of  anything  like  cardinal  importance,"  if  without  evidence 
of  nephritis. 

A  few  words  as  to  the  character  of  the  haematuria  of  renal  calculus 
and  the  fallacies  which  must  be  borne  in  mind.  It  is  a  hsematuria 
of  long  standing,  often  repeated,  frequently  increased  by  exercise  or 
jolting,  rarely  profuse,  and  never  producing  anaemia,  as  in  growth 
of  the  kidney.  Always  intimately  mixed  with  the  urine,  the  tint 
varies  from  a  bright  or  deep  red  (which  I  think  are  rare)  to  a  smoky 
or  porter-like  colour. 

Fallacies  :  (a)  Haematuria  ma}'  be  absent  from  first  to  last.  This, 
an  undoubted  fact,  is  one  veiy  difficult  of  explanation.  It  was  the 
case  with  the  smaller  calculus  (Fig.  40).  And  this  is  the  more 
extraordinary  as  the  stone  is  covered  \\'ith  minute  crystalline  spicules, 
a  condition  which  would  have  appeared  certain  to  lead  to  oozing 
from  the  inflamed  mucous  membrane  of  the  pelvis  in  which  the 
stone  lay.  The  only  explanation  that  I  can  give  is  that  at  the 
operation  I  found  the  abdominal  muscles  extremely  rigid ;  even  when 
the  patient  was  fully  ansesthetised,  they  gave  the  impression  to  the 
scalpel  of  cutting  through  tissues  frozen  by  ether.  Now,  if  it  is  fair 
to  suppose  that  on  the  other  side  of  the  kidney  the  quadratus  and 
psoas  were  as  firmly  contracted,  the  kidney  and  the  stone  in  its 
pelvis  may  have  been  so  firmly  held  that  no  irritation  by  the  calculus 
could  take  place,  and  thus  no  haematuria.  (h)  Another  fallacy  is  that 
the  haematuria  of  calculus  ma}-  be  only  temporar}- ,  present  for  a  while 

*  Being  convinced  of  the  frequency  of  errors  of  diagnosis  in  renal  calculus,  I  have 
dealt  with  these  fully.  I  may  also  refer  my  readers  to  my  paper,  Brit.  Med.  Journ., 
1890,  vol.  i.  p.  117. 


NEPHRO-LITIIOTOMY.  1 1 5 

and  then  ceasing  altogether.  This  occurs,  though  rarely,  when  a  small 
renal  calculus  becomes  encysted,  (c)  The  value  of  heematuria,  though 
only  occasional,  is  shown  by  a  case  of  Dr.  Owen  Rees',  to  which 
Mr.  Morris  has  drawn  attention. 

It  was  that  of  a  youug  lady  with  lumbar  pains  and  frequent  micturition,  which 
were  both  put  down  to  the  hysteria  that  was  markedly  present.  After  a  while, 
haematuria  was  found  to  be  present  ou  several  occasions,  and  eventually,  after 
death,  a  mulberry  calculus  was  found  in  one  kidney. 

Other  fallacies  are  presented  by  the  host  of  kidney  conditions 
which  may  give  rise  to  hasmaturia — namely,  (i)  the  passage  of  uric 
acid  crystals  ;  (2)  tubercular  kidney ;  (3)  granular  kidney  ;  (4)  gro\vths ; 
(5)  increased  intra-renal  pressure,  &c.     To  these  I  shall  refer  later. 

2.  Pain  and  Tenderness,  Licmhar  ami  elsewhere. — (a)  Fixed  Lumbar 
Paix. — Characters  :  Generally  diill.  gnawing,  pricking,  or  aching,  in- 
creased iisually  by  exercise,  twisting  from  side  to  side,  or  flexing  the 
body.*  Sometimes  it  is  relieved  by  pressure  of  the  hand,  leading  to 
thickening  and  vascularity  of  the  parts  when  they  are  incised  at  the 
operation,  (b)  Radiating  Pain,  for  example,  in  the  testis,  f  region 
of  the  small  sciatic  nerve,  calf,  foot,  or  in  the  intestine  simulating 
colic.  It  is  easy  to  see  how  readily  the  pain  of  a  renal  calculus, 
if  limited  to  distant  parts,  and  if  occurring  without  hismaturia,  may 
mislead.  Another  point  ^\•ith  regard  to  the  pain  of  renal  calculus  is 
the  frequency  of  nocturnal  exacerbations.  The  explanation  of  this  is 
doubtful,  whether,  as  Mr.  Morris  has  suggested,  from  the  passage  of 
flatus  in  the  colon,  at  this  time  over  a  stone  in  the  pelvis,  or,  as  I 
venture  to  think  more  probable,  as  accounting  for  stone  whether  in 
the  pelvis  or  in  one  of  the  calyces,  to  the  concentration  of  the  iirine, 
and  consequent  deposit  of  crystals,  which  takes  place  at  night,  is 
unsettled.     The  fact,  however,  is  undoubted. 

In  the  case  of  a  patient,  aged  58.  who  had  suffered  from  symptoms  of  renal  calculus 
for  thirty  years,  and  from  whose  left  kidney  I  removed  the  huge  calculus  (Fig.  40), 
the  pain  at  night  was  often  so  severe  as  to  drive  him  from  his  bed  into  his  garden 
or  the  streets  of  the  town  in  which  he  lived. 

(c)  Renal  Colic. — Very  acute  in  character,  radiating  from  the  loin, 
usually  downwards,  and  accompanied  often  by  rigors,  nausea,  vomiting, 
and  profuse  perspiration.  The  attacks  are  usually  recurrent,  and 
vary  greatly  in  severity. 

On  the  other  hand,  pain  is,  much  more  rarely,  absent. 

With  regard  to  tenderness,  Mr.  Jordan  Lloyd  (Praci.,  vol.  xxxix. 
p.  178),  in  a  paper  to  which  I  shall  have  again  to  refer,  writes 
thus :   "I    attach    great   importance   to   the    evidence    to   be    obtained 

*  As  in  going  upstairs ;  probably  from  the  pressure  on  the  kidney  by  the  contract- 
ing psoas.  But  the  relation  of  the  pain  to  movement,  and  the  kind  of  movement 
which  most  induces  pain,  vary  greatly.  Thus  Mr.  Butliu's  patient  is  said  to  have 
suffered  greatest  pain  when  driving,  least  when  riding.  Prolonged  walking  seems 
the  most  frequent  cause. 

t  In  a  case  of  Mr.  Butliu's  (^Clhi.  Soc.  Trans.,  vol.  xv.  p.  113)  the  patient  sought 
relief  from  severe  neuralgia  of  the  right  testis,  which  was  generally  retracted  and 
extremely  tender.  Later  ou  it  was  noticed  that  these  neuralgic  attacks  were 
associated  with  some  lumbar  pain  and  tenderness.  Complete  recovery  followed  after 
the  removal  of  a  small,  prickly,  calcium-oxalate  calculus  from  the  pelvis  of  the 
right  kidney. 


Il6  OPEEATIOXS  ON  THE  ABDOMEN. 

by  immediate  percussion  over  the  suspected  organ,  a  method  of 
investigation  which  has  not  received  that  amount  of  attention  to 
which  it  is  entitled.  It  is  best  practised  from  the  loin,  just  beneath 
the  space  between  the  tips  of  the  last  two  ribs,  and  should  be 
made  in  a  direction  upwards,  forwards,  and  slightly  inwards.  It  is 
best  for  the  patient  to  stand  upright  before  you.  The  blow  should 
be  sharp  and  decisive,  and  of  force  sufficient  to  affect  a  structure 
situated  several  inches  below  the  surface.  It  may  also  be  practised 
from  the  front,  at  a  point  midway  between  the  umbilicus  and  ninth 
rib.  When  a  calculus  is  present,  the  patient  will  complain  of  sharp, 
stabbing  pain  at  the  moment  of  percussion.  Other  conditions  doubt- 
less give  rise  to  percussion  pain,  but  not  of  the  characteristic  stabbing 
of  calculus." 

I  have  tried  the  percussion  test  of  Mr.  Lloyd  in  many  of  the 
cases  which  have  come  under  my  hands  for  nephro-lithotomy  (table, 
p.  138)  since  his  paper  was  published.  In  three  the  tenderness  was 
increased,  but  in  one  only  was  there  any  "  characteristic  stabbing." 
In  this,  where  a  small  and  very  spiculated  oxalate  of  lime  calculus 
occupied  the  top  of  the  left  ureter,  the  patient  at  once  said,  "  You 
stab  me  there."  This  patient.  No.  5  in  the  table,  was  thin  and 
spare.  Tenderness  more  or  less  marked  will,  however,  be  usually 
elicited  by  making  firm  pressure  upon  the  kidney  between  the  two 
hands,  one  placed  in  front  and  one  behind  the  kidney. 

3.  Points  in  the  Previous  Ilistort/. — Space  will  only  allow  of  my 
noticing  a  few  of  those  given  above,  namely,  lithiasis  and  oxaluria, 
history  of  previous  passage  of  a  stone,  history  of  previous  colic. 

The  history  of  long-standing  lithiasis  and  oxaluria  is  of  obvious 
importance,  from  the  fact  that  the  habitual  passage  of  crystals  or 
gravel  and  the  formation  of  a  calculus  lie  not  far  apart.  But  there 
is  another  point  which  has  not,  I  think,  received  sufficient  attention, 
and  that  is,  that  in  patients  who  have  habitually,  for  many  years, 
passed  uric  acid  and  oxalate  of  lime,  there  is  a  most  serious  risk 
that  the  minute  anatomy  of  their  kidneys  will  have  become  seriously 
damaged  by  the  constant  presence  of  the  above  crystals.  We  should 
all  be  agreed  as  to  the  damaging  effect  of  multiple  calculi  on  the 
secreting  tissue  of  the  kidney.  I  would  suggest  that  in  the  future 
the  results  on  the  kidney  of  the  daily  passage  of  crystals  of  uric 
acid  and  lime  oxalate  must  receive  sufficient  attention  before  patients 
at  all  advanced  in  life  are  submitted  to  nephro-lithotomy.  Further- 
more, it  is  obvious  that  long-continued  lithiasis  and  oxaluria  will 
very  likely  have  led  to  the  formation  of  bilateral  stones. 

Under  the  heading  of  Renal  Colic,  I  would  point  out  that  the 
vomiting  and  nausea  which  are  thought  to  be  characteristic  of  the 
agony  of  a  descending  calculus  may  also  be  caused  by  a  stone  which 
is  distending  the  renal  pelvis,  bi^t  has  not  yet  begun  to  make  its 
way  down. 

4.  Frequency  of  Micturition. — The  co-existence  of  irritability  of  the 
bladder  ^^■ith  renal  calculus  is  well  known,  and  may  be  explained  either 
by  nerve  disturbance,  or  by  the  blood  and  pus,  or  the  over-acid  urine 
which  often  accompanies  stone  in  the  kidney. 

A  point  with  regard  to  bladder  irritability  is  that  it  may  be  of  value 
in    making  that  most   difficult  diagnosis  between   a   calculous    and    a 


XEPHRO-LITHOTOM  Y.  1 1 7 

tubercular  kidnej'.  Thus,  if  a  patient  with  h^ematuria,  lumbar  pain, 
&c.,  has  irritability  of  the  bladder  which  is  not  relieved  by  rest  in  bed, 
but  which  continues  bv  nio-ht  as  well  as  bv  dav,  it  is  probable  that  this 
is  due  not  to  trouble  in  the  kidney  alone,  but  to  co-existmg  ulceration 
of  the  bladder,  and  this  will  probably  be  confirmed  by  examination 
of  the  prostate  and  vesicul^e  seminales  in  the  male,  and  by  digital 
exploration  of  the  bladder  in  the  female. 

5.  Sliagrajyhic  Evidence. — So  mam*  obscure  cases  of  renal  and 
ureteral  calculi  have  now  been  made  clear  by  means  of  radiography 
that,  wherever  the  means  are  at  hand,  cases  that  are  at  all  doubtful 
should  be  submitted  to  this  test.  If  a  distinct  shadow  is  seen  in  the 
skiagram  of  the  affected  side,  it  may  be  taken  to  be  indicative  of  the 
presence  of  a  calculus.  On  the  other  hand,  the  absence  of  a  shadow 
cannot  be  said,  in  the  present  state  of  our  knowledge,  to  prove  the 
absence  of  a  calculus. 

6.  Failure  of  Previous  Treatment  to  ijive  Belief. — I  can  only  touch  on 
one  point  here — i.e..  the  question  of  the  advisability  of  trying  to  exert 
any  solvent  action  on  a  calculus  in  the  kidney.  Whilst,  for  myseli.  1 
attach  the  greatest  importance  to  the  use  of  large  quantities  of  water,  it 
is  rather  because  this,  by  washing  out  the  kidne3's,  removes  collections 
of  crystals,  and  gets  the  patient  into  a  better  state  for  operation,  than 
because  I  believe  in  its  jDOSsessing  any  actively  solvent  action  upon  the 
calculus.  I  do  not  forget  that  Sir  W.  Roberts  has  proved  by  experi- 
ments on  calculi,  both  those  without  the  body  and  those  in  the  bladder, 
that  urine  rendered  alkaline  by  fixed  alkali  has  a  distinctly  solvent 
action. 

Dr.  Ralfe  has  reported  {Path.  Soc.  Trans.,  vol.  xxxiii.  p.  206)  a  case  of  a  i)atient, 
aged  37,  who.  after  sufferiug  from  uric  acid  gravel  for  some  years,  had  a  violent  attack 
of  renal  colic,  with  profuse  haematuria,  no  calculus  or  gravel  being  discharged. 
Alkaline  treatment  was  at  once  resorted  to,  and  for  a  time  afforded  relief,  but  the 
patient  could  not  be  persuaded  to  continue  it  systematically.  He  was  then  ordered  to 
drink  copiously  of  soft  water — filtered  rain-water.  Two  years  later  he  began  to  pass 
grit  and  scales  of  calculous  matter  with  his  urine  ;  and  shortly  afterwards,  after  a 
severe  attack  of  colic,  he  passed  the  sheU.  of  what  had  evidently  been  a  solid  calculus.* 

But  it  must  be  remembered  that,  as  my  late  colleague  Dr.  Hilton 
Fagge  pointed  out  {Medicine,  vol.  ii.  pp.  373.  383).  such  solvent  treat- 
ment is  only  worth  trying  in  the  case  of  uric  acid  calculi.  He  at  the 
same  time  showed  that  the  greater  relative  frequency  of  lime  oxalate 
calculi  over  those  of  uric  acid,  especially  in  patients  after  early  adult 
life,    is    nmch    more    marked    than    is    generally  believed.      ^loreover, 

*  Dr.  Ralfe  (^Dheascs  of  the  Kidmys.  p.  523)  points  out  that  the  solvent  action  of 
distilled  water  is  due  to  several  influences.  In  the  first  place,  by  causing  a  low  specific 
gravity  of  the  urine,  it  induces  disintegration,  since  Kainey  has  shown,  experimentally, 
that  bodies  placed  in  solutions  of  different  density  to  those  in  which  they  were  formed 
undergo  molecular  disintegration.  Again,  chemical  analysis  has  shown  that  those 
calculi  that  undergo  spontaneous  disintegration  are  always  poor  in  inorganic  con- 
stituents: the  use  of  soft  water  diminishes  the  supply  of  these,  even  if  it  does  not 
actually  act  as  a  solvent  on  those  forming  the  outer  crust  of  the  calculus,  and  so 
increases  the  tendency  to  disintegration.  Lastly,  soft  water  probably  diminishes  the 
catarrh  of  the  urinary  passages,  and  by  diminishing  the  swelling  of  the  mucous  mem- 
brane allows  a  small  stone  to  pass  which  was  before  obstructed. 


Il8  OPERATIONS  ON  THE  ABDOMEN. 

as  Morris  {Hunterian  Lectures,  1898)  points  out,  it  cannot  be  too 
strongly  urged  that,  in  the  presence  of  definite  symptoms  of  calculus, 
any  prolonged  course  of  palliative  treatment  is  to  be  deprecated,  for 
during  this  time  the  stone  may  be  steadily  but  slowly  destroying  the 
kidney,  and  so  valuable  time  will  be  lost. 

7.  Calculous  AmLTia. — Exploration  of  the  kidney  in  this  extreme 
condition  is  urgently  called  for,  although  in  a  few  cases  recovery  has 
taken  place  without  operation.  Morris  Qoc.  sujfra  cit.)  gives  two  collec- 
tions of  cases,  those  operated  on  and  those  not  operated  on.  Of  forty- 
eight  cases  not  operated  on,  ten,  or  20"8  per  cent.,  recovered  ;  of  forty- 
nine  cases  operated  on,  twenty-five,  or  51  per  cent.,  recovered.  These 
figures  speak  for  themselves. 

The  most  important  and  difficult  point  to  decide  is  the  question  as  to 
which  kidney  should  be  explored.  If  it  can  be  determined  which  kidney 
has  become  the  more  recently  affected,  this  should  be  chosen  for  operation, 
because  this  kidney  will  be  the  one  that  is  least  destroyed  by  disease. 
Apart  from  history,  abdominal  pain,  rigidity,  and  tenderness  may  help  to 
clear  up  this  point.     This  subject  is  again  referred  to  later,  p.  137. 

Conditions  which  may  simulate  Renal  Calculus. — Before  deciding 
to  operate  on  a  given  case,  it  must  be  borne  in  mind,  in  addition  to  what 
has  been  already  said,  that  many  other  diseases  may  give  rise  to  the 
same   symptoms  as  renal  calculus. 

So  closely  do  some  of  these  conditions  simulate  renal  calculus  that  a 
correct  diagnosis  can  only  be  arrived  at  by  means  of  an  exploratory 
operation.  Morris  (Joe.  supra  cit.)  gives  a  list  of  no  less  than  forty-four 
cases  occurring  in  his  own  practice  in  which  the  kidney  was  explored  for 
stone,  and  no  stone  found.  In  a  few  of  the  cases  a  calculus  was  passed 
soon  afterwards,  so  may  have  been  lodged  in  the  ureter  at  the  time  of 
the  operation.  In  the  majority  of  the  cases,  however,  some  other  morbid 
condition  of  the  kidney  or  ureter  was  found  and  remedied.  So  that, 
although  no  stone  was  found  as  the  result  of  these  operations,  no  harm 
was  done  in  any  (for  none  were  fatal),  and  good  was  done  in  the 
majority.  Morris  says :  "It  is  certain  that  the  diagnosis  of  calculus, 
though  incorrect,  was  advantageous  to  the  patients,  for  the  very  reason 
that  it  led  to  the  exploration,  and  in  this  way  to  the  discovery  of  the 
true  cause  of  the  disease." 

These  conditions  simulating  calculus  must  now  be  severally  con- 
sidered. They  may  be  usefully  divided  into  two  groups — affections  of 
the  kidney  and  ureter,  and  diseases  of  other  organs. 

A.  Affections  of  the  kidney  and  ureter  which  simulate  renal 
calculus. 

1.  Lithiasis. — I  have  already  alluded  to  this  condition  as  one  which 
simulates  renal  calculus  by  the  hfematuria  which  crystals  of  uric  acid 
may  cause.  Lumbar  and  testicular  pains  are  also  points  which  mere 
lithiasis  shares  with  renal  calculus.  The  diagnosis  will  not  be  difficult 
by  watching  the  result  of  treatment,  which  only  gives  relief  in  the  one, 
but  clears  up  the  other.     Exercise,  again,  is  a  test. 

2.  Tubercular  Kidneij. — Lumbar  pain  and  tenderness,  frequent  mic- 
turition, haomaturia,  are  all  common  to  tubercular  kidney  and  renal 
calculus.  The  chief  aids  in  the  diagnosis  appear  to  me  to  be  :  (a)  the 
pyuria;  (6)  careful  examination  of  the  urine ;  (c)  early  pyrexia;  ((Z)  early 
exploration  of  the  kidney. 


NEPHRO-LITIIOTOMY.  II9 

{a)  Pyuria. — This  is  usually  present  early  in  the  case  with  a  pro- 
portionate amount  of  albumen,  without  much  hgematuria,  the  blood 
often  occurring  only  as  a  thin  layer  over  the  pus  at  the  bottom  of  the 
itrine-glass,  or  as  small,  thready  clots.  With  all  the  pus  the  urine  is 
strongly  acid  at  first,  then  more  feebly  so,  but  often  remains  slightly 
acid  to  the  last,  (ft)  Careful  examinations  of  the  urine. — The  sediment 
contains  caseous  matter,  and  sometimes  debris  of  connective  tissue  can 
be  made  out,  a  point  of  much  importance.  Finally,  there  is  the  bacillus 
tuberculosis.  While  I  am  well  aware  of  the  frequent  want  of  success 
in  demonstrating  the  presence  of  the  bacillus  in  urine  as  in  bone,  I  may 
add  that  it  was  found  in  six  out  of  the  thirteen  cases  in  which  I  have 
been  asked  to  explore  tubercular  kidneys.*  (c)  Pyrexia. — I  do  not  here 
speak  of  the  hectic  which  accompanies  the  advanced  stage,  but  of  the 
pyrexia  which  may  be  an  important  factor  in  the  diagnosis  much  earlier 
in  the  case.  Often  intermittent  at  first,  and  liable  to  be  overlooked  in 
the  anorexia,  nausea,  and  debility  which  accompany  it,  later  on,  and  too 
late,  it  becomes  only  too  evident  and  confirmed,  {d)  Early  exploration 
of  the  kidney. — Morris  mentions  three  cases  in  which  tuberculous  foci 
were  found  in  the  kidney  and  excised.  In  one  case  three  separate 
wedges  of  kidney  substance  Avere  removed,  and  the  resulting  gaps  in 
the  kidney  closed  by  sutures.     This  matter  is  referred  to  later,  p.  158. 

3.  Hydrmiephrosis  due  to  stricture  of  the  ureter,  or  a  vahmlar 
obstruction  at  the  commencement  of  the  ureter.  Several  remarkable 
cases  of  this  nature  have  been  described,  notably  those  of  Morris  and 
Fenger.  These  will  be  referred  to  later,  p.  169.  Mr.  Bruce  Clarke  has 
also  published  {Lancet,  vol.  ii.  1891,  p.  984)  two  cases  of  this  kind  in 
which  the  cause  was  not  found.  The  first  was  perhaps  an  early  stage 
of  hydronephrosis,  and  the  pain  a  very  prominent  feature,  dull  and 
aching,  with  severer  attacks ;  but,  as  it  was  found  at  the  operation  that 
"'the  kidney  pelvis  was  very  slighth^  dilated,"  the  case  is  not  decisive. 
The  second  is  more  convincing.  The  kidney  here  was  dilated  and  a 
mere  shell,  no  cause  being  found.  There  was  a  definite  history  of 
several  attacks  of  renal  colic,  and  Mr.  Bruce  Clarke  thought  that  these 
had  probably  been  caused  by  kinking  of  the  ureter. 

4.  Slight  Pyelitis,  not  Tid>ercular. — This  condition  may.  by  hsematuria, 
pus  in  the  urine,  lumbar  and  testicular  pain,  simulate  renal  calculus 
closely.  It  may  follow  a  gonorrhoea,  perhaps  a  previous  stone,  or  occur 
in  women  after  pregnancy ;  perhaps,  as  Dr.  ^I.  Duncan  thinks,  from 
some  parametritis  extending  up  the  psoas  to  the  peri-renal  fat  and 
kidney. 

*  I  may  point  out  here  that  bacteriology  will  help  the  surgeon  iu  difBcult  cases. 
My  colleague,  Dr.  Washbourne,  has  thus  cleared  up  two  obscure  cases  for  me.  One, 
a  delicate  woman  of  32,  with  a  tubercular  history,  was  sent  to  me  by  Dr.  Forty, 
of  Wotton,  in  Gloucestershire,  with  obstinate  cystitis  and  irritable  bladder.  The 
endoscope  and  digital  exploration  showed  swollen  and  hyper-vascular  mucous  mem- 
brane, but  detected  no  ulceration.  AViping  over  the  mucous  membrane  with  a  solution 
of  silver  nitrate  (gr.  xl. — 5j)  was  followed  by  very  great  relief  lasting  over  two  months 
on  two  occasions.  At  my  request  Dr.  Washbourne  injected  some  of  the  pus  containing 
urine  (in  which  no  bacilli  could  be  found)  under  the  skin  of  a  guinea-pig.  No  result 
apparently  followed,  but,  when  the  animal  had  been  killed,  oiw  of  the  nearest  chain  of 
glands  was  enlarged  and  caseating.  A  few  undoubted  bacilli  tuberculosis  were  found 
in  it.     This  and  the  other  case  will  be  found  in  the  Gtafs  Hasp.  Bcp.-,  1890. 


I20  OPERATIONS  ON  THE   ABDOMEN. 

5.  Movable  Kidney,  especially  if  associated  with  neuralgia,  pyelitis,  or 
if  recurring  with  some  of  the  reflex  causes  of  nephralgia  to  be  mentioned 
below.  The  following  case  under  Mr.  Watson  Cheyne  (Brit.  Med. 
Journ.,  vol.  i.  1899,  p.  17),  in  which  there  was  severe  hematuria, 
caused  probabl}^  by  congestion  due  to  kinking  of  the  renal  vessels,  is 
Avorthy  of  note  in  this  connection. 

A  woman,  aged  40,  had  a  fall,  hurting  her  back,  in  1885.  This  caused  great  pain 
and  hsematuria,  the  urine  being  bright  red  in  colour.  This  continued  for  five  weeks, 
during  which  time  the  patient  was  confined  to  bed.  and  then  ceased.  There  was  no 
further  hsematuria  for  ten  years,  although  pain  was  present  during  most  of  the  time, 
Severe  hsematuria  then  occurred  again,  and  again  stopped  after  a  time.  In  June  1897, 
severe  hsematuria  and  pain  came  on  again,  and  continued  till  November,  when  the 
operation  was  performed.  No  stone  was  jDresent,  but  the  kidney  was  found  to 
be  freely  movable.  The  kidney  was  fixed,  with  the  result  that  hsematuria  ceased 
immediately  and  did  not  recur. 

6.  Ureteritis. — The  following  is  a  very  striking  instance  of  this  rare 
disease,  described  by  Israel  {Berl.  Klin.  Woch.,  xxvii.,  1893)  : 

A  young  man.  aged  28.  had  for  eight  years  suffered  from  a  urinary  affection 
which  began  with  frequency  of  micturition.  Soon  acute  attacks  of  pain  in  the 
bladder  and  left  renal  colic  of  extraordinary  severity  began.  The  clinical  examination 
in  corroboration  of  the  patient's  account  left  no  doubt  as  to  the  presence  of  renal 
calculus :  there  were  frequently  blood  and  mucus,  but  no  tubercle  bacilli,  present  in  the 
urine;  there  was  also  tenderness  in  the  left  flank,  and  pain  was  caused  by  pressure  on 
the  ureter  through  its  abdominal  course.  The  kidney  was  explored,  and  found  to  be 
small  and  soft,  but  no  calculus  was  present.  The  wound  healed  rapidly,  but  the 
symptoms  continued  as  bad  as  ever. 

Two  months  and  a  week  later  the  kidney  was  again  explored,  and  then  it  was  dis- 
covered that  the  ureter  througliout  its  length  was  extraordinarily  hard,  of  nearly  three 
times  its  normal  diameter,  and  presented  at  intervals  enlargements  of  quite  carti- 
laginous consistence.  The  ureter  was  permeable  from  kidney  to  bladder,  but  at  three 
points  slight  obstructions  were  present,  due  to  folds  of  thickened  mucous  membrane, 
the  result  of  ureteritis.     Nephrectomy  was  performed,  and  resulted  in  a  complete  cure, 

7.  Aching  Kidney. — Under  this  title  Dr.  M.  Duncan  has  described  a 
condition,  especially  common  in  women,  which  ma}''  simulate  renal 
calculus.  Its  chief  features  are  a  heav}',  wearying  pain,  deep  in  the 
side,  usually  accompanied  b}"  tenderness,  often  great ;  the  pain  may  run 
in  the  course  of  the  great  sciatic  or  anterior  crural,  and  is  frequently 
accompanied  by  irritability  of  the  bladder,  and  by  pain  in  the  course  of 
the  ureter.  The  disease  is  liable  to  be  aggravated  by  exercise.  The 
chief  points  in  the  diagnosis  of  this  condition  are,  Dr,  Duncan  points 
out,  the  absence  of  blood  and  pus,  the  fact  that  the  "  aching "  often 
occurs  onl}'  at  the  menstrual  periods  and  is  always  worse  then,  from  the 
intimate  connection  between  the  kidneys  and  the  generative  organs,  not 
only  developmental  but  pathological,  A  definite  nephralgia  is  also 
caused  sometimes  by  malaria,  as  pointed  out  by  Morris,  and  ma}'  be 
relieved  by  the  administration  of  quinine. 

8.  Interstitial  8hrviildn(j  Nephritis. — This  condition  may  simulate 
renal  calculus  both  by  hsematuria  and  pain. 

Dr.  S,  West  {Lancrt,  1885.  vol.  ii.  p.  104)  drew  attention  to  the  htematuria  which 
may  accompany  granular  kidney,  and  published  three  cases,  aged  21,  19,  and  24 ;  in  the 
first  the  haemorrhage  was  profuse.  Mr.  Bowlby  {Clin.  Soc.  Trans.,  vol.  xx.  p.  14)  also 
published  three  cases,  aged  73,  49,  and  64 ;   two  of  these  died,  and  the  kidneys  were 


NEPHRO-LITHOTOM  Y.  121 

found  markedly  granular.  He  points  out  the  following  as  distinguishing  this  condition 
from  renal  calculus :  The  specific  gravity  of  the  urine,  after  the  blood  has  cleared  up, 
only  1008  to  1015;  tortuous  arteries,  cardiac  hyperti'ophy,  and  high  arterial  tension; 
blurred,  ill-defined  discs,  some  retinitis  and  effusion  amongst  the  blood-vessels.  The 
paper  concludes  with  the  following  warning :  ••  Unless  it  be  recognised  that  blood  may 
emanate  from  a  kidney  which  is  simply  granular,  operations  may  be  undertaken  for  the 
removal  of  renal  calculus." 

With  regard  to  renal  pain  in  granular  kidney,  this  is  of  two  kinds. 
There  is  the  dull  aching  generally  found,  if  the  case  be  watched,  to  be 
felt  across  both  loins,  as  well  as  in  one  side.  Occasionally,  though 
this  is  rarer,  the  pain  occurs  in  violent  paroxysms,  simulating  renal 
colic.  This  was  so  in  the  case  to  which  I  have  alluded,  and  to  a  more 
marked  degree  in  one  brought  by  Mr.  Mansell  Moullin  before  the 
Clinical  Societj^  (TraMS.,  vol.  xxv.  p.  60).  If  now,  in  addition  to  the 
hgematuria  and  paroxysmal  pain,  there  be  nausea,  passage  of  uric  acid, 
and  frequent  micturition,  the  mistaken  diagnosis  of  calculus  maj'  easily 
be  made.  Where  granular  kidne}-  is  possible,  such  a  case  should  be 
carefully  watched,  and  if  the  specific  gravity  of  the  urine  never  rises 
above  1015,  the  question  of  operation  must  be  entertained  with  the 
greatest  caution,  and  the  very  great  risks  most  clearly  put  before  the 
patient. 

Other  conditions  mentioned  b}^  ^lorris  as  having  been  found  in  some 
of  the  above-mentioned  forty-four  cases  are — small  abscesses,  or  sup- 
purating c^'sts,  solid  renal  or  peri-renal  tumours,  tense  cysts,  blood 
extravasated  either  under  the  capsule  or  within  the  substance  of  the 
kidney,  dense  adhesions. 

B.  Diseases  of  other  organs  which  may  simulate  renal  calculus. 

1.  Gastric  and  Duodenal  Ulcer. — Morris  has  seen  a  case  of  gastric 
ulcer  which  sinnilated  renal  calculus,  and  Ralfe  (Brit.  Med.  Joiirn.,  1888, 
vol.  i.  p.  183)  gives  one  which  he  thinks  was  due  to  duodenal  ulcer. 

Thus,  a  patient  had  many  symptoms  of  renal  colic,  and  three  attacks  of  paroxysmal 
pain  accompanied  by  vomiting,  great  tenderness  in  the  right  renal  region,  urine  loaded 
with  uric  acid,  but  no  pus  or  blood.  The  patient,  who  was  losing  flesh,  recovered  with 
treatment  directed  to  duodenal  ulcer. 

2.  Litest inal  Adhesions. — A  case  is  given  by  Dr.  Tirard  (Lancet,  vol.  i. 
1892,  p.  16).  Though  (as  the  kidney'  was  only  punctured)  the  presence 
of  a  calculus  cannot  be  excluded  in  this  case,  it  is  very  possible  that  the 
exi3lanation  given  below  may  meet  other  nephralgias.  A  schoolboy, 
aged  12,  gave  a  history  of  ha^maturia  with  severe  pain,  after  another 
boy  had  jumped  suddenly  and  roughly  on  his  back.  There  was  only 
this  one  attack  of  hematuria,  but  from  this  time  occurred  frequent 
attacks  of  severe  pain,  which  seemed  to  return  with  any  sudden  jolting 
movements,  a  railway  journey  or  a  ride  in  a  hansom  often  proving 
sufficient  exciting  cause.  It  was  also  noticed  that  the  pain  was  worse 
with  constipation  or  diarrhoea.  Although  no  certainty  was  felt  about 
the  presence  of  a  renal  calculus,  it  was  generally  thought  that  the 
sj'mptoms  might  be  due  to  this.  At  the  operation  no  stone  could  be 
found,  though  the  pelvis  and  the  substance  of  the  kidney  were  carefully 
explored  with  a  needle.  A  firm  cicatrix  was,  however,  discovered,  circling 
the  capsule  of  the  kidney  and  the  descending  colon,  and  this  was  so 
tough  and  so  extensive  that  it  was  thought  expedient  not  to  divide  it. 


122  OPERATIONS  OX  THE  ABDOMEN. 

The  lad  recovered,  and  is  now  able  to  keep  fairly  free  from  pain  so  long- 
as  he  attends  closely  to  the  action  of  the  bowels. 

3.  Gall  Stones  retained  in  the  Gall  Bladder  may  be  taken  for  right 
renal  calculus.  Dr.  Murchison  pointed  out  long  ago  that  they  not 
infrequently  coexist.  My  old  friend.  G.  A.  Wright,  of  Manchester, 
has  recorded  {Lancet,  1885,  vol.  i.  p.  563)  a  case  in  which  the  right 
kidney  was  explored  for  a  calculus  believed  to  be  in  the  ureter. 

On  exploring  this  tube  a  hard  spot  was  felt  near  the  brim  of  the  pelvis,  and  taken 
for  a  stone  in  the  ureter.  A  calculus  the  size  of  a  pigeon's  egg  was  removed  and  found 
to  be  a  gall-stone.  Acute  peritonitis  carried  off  the  patient,  and  a  stone  was  found  to 
exist  in  the  pelvis  of  the  right  kidney,  with  its  apex  in  the  ureter. 

While  on  this  subject  of  nephralgias  due  to  conditions  of  viscera  near 
the  kidney,  I  may  refer  to  some  remarks  of  Mr.  Godlee  (Pract.,  vol. 
xxxix.  p.  246).  in  which  he  insists  that  repeated  attacks  of  intestinal 
colic,  especially  if  accompanied  by  nausea,  may  be  the  only  symptoms  of 
the  presence  of  either  a  renal  or  biliary  calculus,  and  that  this  fact 
should  lead  the  practitioner  to  investigate  the  state  of  the  kidney  and 
urine,  bearing  in  mind  the  possibility  of  the  symptoms  being  due  to 
renal  or  biliary  calculi. 

4.  Sjjinal  Disease. — The  great  difficulty  which  may  arise  in  diagnos- 
ing between  certain  cases  of  spinal  caries  and  renal  calculus  is  not  yet 
sufficiently  recognised.  A  writer  already  quoted  from  (G.  A.  Wright, 
Med.  Chron.,  No.  vi.  p.  642)  thus  alludes  to  this  matter  : 

"  Where  a  local  patch  of  caries  of  a  vertebral  body  exists,  and  especially  where  deep 
suppuration  occurs  and  presses  upon  the  kidney,  as  in  a  case  of  my  own  and  one  or  two 
others  which  I  have  seen,  nearly  all  the  symptoms  of  a  calculus  have  been  present. 
In  my  own  case,  without  any  deformity  or  tenderness  of  the  spine,  there  was  unilateral 
rigidity,  testicular  pain,  intermission  of  symptoms,  increased  frequency  of  micturition, 
nausea  during  attacks,  and  oxaluria,  with  local  pain  and  tenderness.  Subsequently  an 
abscess  developed,  and  on  exploration  a  small  patch  of  caries  was  found,  and  the 
kidney  was  felt  exposed  in  the  anterior  wall  of  the  abscess  cavity.  Probably,  as  in 
floating  kidney,  obstruction  of  the  vessels  and  ureter  may  arise  and  cause  symptoms, 
so  that  pressure  of  the  spinal  abscess  may  disturb  the  kidney,  and  quite  possibly  give 
rise  to  hEematuria." 

In  addition  to  the  above,  Morris  alludes  to  having  known  cases  of 
each  of  the  following  conditions  give  rise  to  symptoms  simulating  renal 
calculus : — malignant  and  tuberculous  growths  in  the  intestines,  aortic, 
or  coeliac  aneurysm  stretching  the  ureter  or  renal  vessels,  vesical  calculus, 
abscess  and  calculus  in  the  prostate,  growths  in  the  bladder,  ovaritis, 
and  tuberculous  disease  of  the  Fallopian  tube.  Finally,  I  must  mention 
the  following  exceptional  case  of  malignant  disease  inrolvinrj  the  last 
dorsal  nerve,  that  came  under  my  care  seventeen  years  ago : 

The  patient,  aged  44,  came  with  hsematuria,  wearing  pain,  tenderness  in  the  right 
loin  and  thigh,  and  oxaluria.  His  childhood  had  been  passed  in  Norfolk,  and  as  a 
lad  he  had  been  cut  by  Mr.  Birkett  for  stone  in  the  bladder.  I  sounded  him  twice, 
and  finding  no  stone,  I  swept  the  sound  in  contact  with  the  bladder  in  different 
directions,  in  the  hope  of  detaching  fragments  of  growth  if  one  were  present.  No 
relief  being  given  by  drugs,  I  explored  the  right  kidney,  and  could  find  nothing 
abnormal.  Four  days  after  the  operation,  when  all  seemed  to  be  doing  well,  the 
patient  died  very  suddenly.  At  the  necropsy  we  found  (a)  a  primary  carcinomatous 
growth  of  the  bladder  of  a  somewhat  unusual  kind ;  it  involved  the  apex  as  a 
flocculeut,  superficially  ulcerated  area ;  (i)  a  ring  of  secondary  deposit  surrounding 


NEPHEO-LITHOTOM  Y.  1 2  3 

the  right  last  dorsal  nerve,  just  at  its  exit  from  th'e  spine  ;  (c)  a  mass  of  enlarged 
glands  around  the  inferior  vena  cava,  and  at  one  spot  sprouting  into  it ;  (<Z)  the  left 
kidney  contained  a  large  branching  calculus. 

Operation. — The  patient  being  in  much  the  same  position  as  that  for 
lumlDar  colotomy,  on  the  sound  side,  with  a  firm  pillow  under  the 
opposite  flank,  the  surgeon  defines  carefully  the  lower  border  and 
length  of  the  last  rib.  That  this  is  not  an  unimportant  detail  in  renal 
operations  is  proved  by  the  following  : 

Prof.  Dumreicher,*  of  Vienna,  accidentally  opened  the  pleural  cavity  during  an 
attempt  to  remove  a  pyonephrotic,  calculous  kidney.  At  the  necropsy  it  was  found 
that  the  last  rib  was  rudimentaiy,  that  the  pleura  projected  a  good  deal  below  the 
lower  edge  of  the  eleventh  rib,  and  that  thus,  when  the  incision  was  carried  upwards, 
the  accident  had  become  unavoidable.  Dr.  Lange,  of  New  York,  has  called  attention 
to  the  investigations  of  Dr.  HoU,f  of  Vienna,  on  the  frequency  of  rudimentary 
development  of  the  last  rib,  and  the  importance,  therefore,  of  counting  the  ribs  before 
intended  operations  on  the  kidney.  Dr.  Lange  J  himself  shows  that  in  some  cases, 
which  are,  however,  exceptional,  even  normal  development  of  the  twelfth  rib  may 
demand  extreme  caution,  as  the  pleura  may  project  considerably  below  it.  § 

The  surgeon,  having  defined  the  length  and  position  of  the  lowest 
rib,  makes  an  oblique  incision,  at  least  4  inches  long,  \  inch  below 
it,  and  beginning  about  2h  inches  from  the  spine.  The  skin  and 
fasciae  being  divided,  the  muscles — ^nz.,  anterior  fibres  of  the  latis- 
simus  dorsi,  the  external  and  internal  oblique — are  cat  through,  either 
on  a  director,  or  simply  by  light  sweeps  of  the  knife.  As  soon  as  the 
yellowish-white  lumbar  fascia  is  reached,  any  bleeding  vessels,  which 
have  been  temporarih'  secured  by  Spencer  Wells's  forceps,  are  tied  or 
twisted.  If  the  last  dorsal  nerve  cross  the  incision,  it,  together  with 
its  accompanying  vessels,  should  be  drawn  aside  and  left  untouched 
if  possible.  The  lumbar  fascia  is  next  slit  up  on  a  director.  The  peri- 
renal fat,  which  now  bulges  into  the  wound,  is  torn  through,  ^\ith 
two  large  retractors  opening  up  the  wound,  the  surgeon  continues  to 
tear  through  the  above  fat  ||  till  he  can  see,  or  easily  feel,  the  posterior 
surface  of  the  kidney.  Injury  to  the  peritonaeum  (p.  128)  is  best  avoided 
by  keeping  close  to  the  outer  edge  of  the  quadratus  lumborum.  During 
this  first  stage  of  the  opei-ation  the  surgeon  will  find  sometimes  that 
the  muscles  are  much  thickened  by  reflex  irritation  from  the  presence 
of  the  stone,  and,  if  the  stone  has  been  associated  with  suppuration 
and  peri-renal  inflammation,  the  tissues  will  be  more  or  less  densely 
blended  and  matted  together. 

*  Quoted  by  Dr.  Lange,  loc.  supra  cit. 

t  Dr.  Holl  found  that  in  quite  a  considerable  percentage  the  last  rib  is  so  abnormally 
short  that  it  does  not  reach  as  far  as  the  outer  border  of  the  sacro-lumbalis,  or  so  rudi- 
mentary that  in  some  cases  it  more  resembles  a  transverse  process ;  and  that  in  these 
cases  the  lower  edge  of  the  pleura  passes  from  the  lower  boundary  of  the  last  dorsal 
vextebra  almost  horizontally  towards  the  lower  edge  of  the  eleventh  rib, 

t  Annals  of  Surgery,  vol.  ii.,  Oct.  1885,  p.  286. 

§  In  other  cases  the  reverse  condition  may  be  present ;  though  the  last  rib  be  rudi- 
mentary, the  pleura  may  pass  from  the  lower  edge  of  the  eleventh  dorsal  vertebra 
horizontally  towards  the  eleventh  rib,  and  thus  be  altogether  out  of  danger. 

II  If  this  fat  is  very  abundant,  some  of  it  should  be  carefuUy  torn  away;  poorly 
vitalised,  it  is  prone  to  suppurate  tediously  ami  to  delay  healing. 


124  OPERATIONS   ON  THE  ABDOMEN. 

An  assistant  now  makes  powerful  pressure  on  the  opposite  side  of 
the  abdomen,  so  as  to  keep  the  kidney  up  into  the  wound,  this  being 
widely  opened  by  full-sized  retractors,  aided,  if  needful,  b}^  an  assistant 
pulling  up  the  lower  ribs  with  his  hand.  Thus  the  surgeon  is 
enabled  to  examine  the  organ,  which  is  done  systematically :  the 
linger  is  first  directed  to  the  pelvis,  then  to  the  posterior  surface;  next, 
by  passing  the  finger  round  the  outer  border,  to  the  anterior  surface, 
which,  as  Mr.  Howse  has  pointed  out  {Glin.  Soc.  Trans.,  vol.  xvi.  p.  93), 
can  be  done  effectually  by  pressing  the  kidney  back  against  the  firm, 
unyielding  psoas.  The  sensation  given  by  a  stone  has  been  compared 
to  that  of  the  uncut  end  of  a  pencil  (Morris),  or  the  last  joint  of  a  finger 
(Howse). 

If  the  above  means  fail,  the  incision  must  be  made  sufficiently  free, 
especially  in  a  fat  patient,  and  a  deep  loin,  to  expose  the  kidney  more 
thoroughly.  Additional  room  maj'  be  gained  by  converting  the  usual 
lumbar  incision  into  a  T-shaped  one,  or  by  making  use  of  Konig's 
incision,  in  which  the  muscles  are  cut  through  as  far  as  the  rectus, 
and  the  peritonfeum  pushed  forwards,  or,  as  recommended  by  Morris, 
continuing  the  original  incision  downwards  and  forwards  to  a  point 
one  inch  above  and  in  front  of  the  anterior  superior  iliac  spine.  A 
small  stone  in  the  kidney  will  always  l^e  liable  to  be  overlooked  ;  but 
a  surgeon  does  not  give  his  patient  or  himself  a  fair  chance  who  is 
content  with  exposing  jjart  of  the  kidney  through  a  limited  incision, 
and  then  trusting  to  punctures  ^\•ith  a  needle. 

If  the  stone  cannot  be  felt  either  in  the  pelvis  or  after  palpation 
of  the  posterior  and  anterior  surfaces  of  the  kidney,  this  should  be 
drawn  up  and  out  of  the  wound  as  far  as  possible,  and  again  examined, 
a  careful  watch  being  kept  upon  the  pulse. 

When  the  kidney  cannot  be  brought  out  on  to  the  loin,  the  incision 
should  be  made  large  enough  to  see  what  is  being  done. 

If  no  stone  can  be  felt  b}'  the  exploring  finger,  a  needle  firmly  held 
in  Spencer  Wells's  forceps  should  be  thrust  into  the  different  parts  of 
the  organ,  exploring  it  by  successive  punctures  made  at  short  distances  ; 
twelve  or  more  such  punctures  may  be  made. 

All  the  above,  including  palpation  of  the  kidney  between  the  finger 
and  thumb,  failing,  the  kidnej'  itself  or  the  pelvis*  must  be  incised,  and 
explored  with  a  sound  and  the  finger.  During  this  part  of  the  opera- 
tion, haemorrhage  is  prevented  either  by  compressing  the  renal  vessels 


*  In  the  following  case,  under  the  care  of  Mr.  T.  Jones,  of  Manchester  QMed. 
Chron.,  June  1887,  p.  212),  opening  the  pelvis  alone  sufficed  to  find  the  stone, 
after  systematic  exploration  of  the  kidney  had  failed :  •'  The  forefinger  was  passed 
to  the  anterior  surface,  and  the  organ  grasped  between  the  finger  and  the  thumb; 
nothing,  however,  could  be  found.  The  kidney  was  then  carefully  explored  by 
systematic  puncture  with  a  long  needle,  also  passed  towards  the  pelvis,  but  no 
calculus  could  be  felt.  An  incision,  sufficiently  large  to  admit  the  tip  of  the  index 
finger,  was  then  made  through  the  kidney  substance  into  the  pelvis  by  means  of 
a  fine  bistoury.  On  introducing  the  forefinger,  a  small  stone  was  discovered  firmly 
lodged  in  one  of  the  superior  calyces.  Small,  straight,  lithotomy-forceps  were  intro- 
duced, and  the  stone  thus  removed."  Very  free  luemorrhage  attended  the  above 
incision,  but  it  yielded  to  pressure  made  with  carbolised  sponges,  and  kept  up  for 
five  minutes.  The  patient  made  a  good  recovery.  The  calculus,  consisting  of  lime 
oxalate,  weighed  twenty  grains.     This  plan  of  opening  the  pelvis  might  be  thought 


NEPHRO-LITHOTOMY.  1 2  5 

between  the  left  thumb  and  index  finger,  or,  as  advised  by  Cumston  of 
Boston  (Ann.  of  Sun/.,  vol.  xxvi.  p.  320),  by  means  of  a  special  clamp 
which  he  has  devised  for  the  purpose.  Cumston  finds  that  pressure  may 
be  kept  up  by  this  means  as  long-  as  half  an  hour  without  harm  resulting, 
the  operation  being  accomplished  without  any  loss  of  blood.  A  free 
incision  is  made  through  the  convex  border  of  the  kidney  into  the 
pelvis,  and  a  thorough  and  systematic  examination  of  each  cal\TC 
carried  out  by  means  of  the  index  finger  or  a  short-beaked  child's 
bladder-sound.  The  beak  should  be  not  more  than  a  third  of  an  incli 
in  length,  a  stem  of  about  seven  inches,  and  the  size  of  a  No.  3  English 
catheter.  The  position  of  the  calculus  having  been  made  out,  it  is 
removed,  if  small,  through  the  incision  in  the  convex  border  of  the 
kidney.  If  this  is  inconvenient,  or  the  stone  large,  an  incision  is  made 
directly  over  it,  and  the  stone  then  removed.  It  is  quite  immaterial 
whether  this  incision  is  made  into  the  renal  parenchyma  or  the  pelvis, 
provided  that  it  is  sutured  afterwards. 

If  tlie  stone  is  irregularly  branched,  some  laceration  of  the  kidney 
tissue  may  be  spared  if  the  calculus  is  broken  up  and  removed  in  two 
or  more  fragments.  In  this  case  the  bed  of  the  stone  should  be  freely 
washed  out  with  hot  boracic  acid  lotion  or  Thompson's  fluid,*  so  as  to 
check  oozing  and  remove  all  dehris.'\  Mr.  H.  Morris  {Brit.  Med.  Journ., 
Nov.  16,  1889)  thus  alludes  to  two  difficulties  which  these  stones  may 
cause: — "A  large  branched  calculus  may  be  so  tightly  embraced  by 
the  kidney  substance,  and  the  kidney  may  be  so  uniformly  even  on  its 
surface,  that  nothing  more  than  a  very  firm  tough  organ  may  be  thought 
to  be  present,  and  even  on  passing  a  needle  into  it  no  sense  of  calciilus, 
but  rather  the  resistance  of  a  tough  fibroma,  is  met  with.  In  these 
cases  much  difficulty  will  be  experienced  in  freeing  the  stone  from  its 
encasement,  and  for  this  purpose  the  moderately  free  use  of  a  bistoury 
will  be  requisite.  It  is  astonishing  how  some  of  the  large  branches 
of  a  calculus  may  escape  detection  unless  the  surgeon  is  aware  of  the 
firmness  with  which  they  are  embraced  by  the  tough  renal  tissue. 
After  removing  several  large  pieces  of  calculus  I  have,  in  one  or  two 
cases,  thought  that  all  must  have  come  away,  because  with  my  finger 
in  the  kidney  nothing  but  renal  tissue  could  be  felt,  and  yet,  after 
scratching  through  at  some  points  where  the  resistance  was  greater 
than  elsewhere,  branch  after  branch  of  calculus  has  been  exposed, 
showing  that  more  of  the  calculus  would  have  been  left  behind  than 
had  been   removed  had  the  operation   been   discontinued,  because  no 

to  cause  a  risk  of  leaving  a  urinary  fistula,  but  the  numerous  cases  in  which  calculi 
have  been  removed  from  the  renal  pelvis  with  entire  success  do  not  support  this  vicvr. 
If  the  pelvis  be  dilated  this  spot  should  be  chosen,  otherwise  I  generally  incise  the 
convex  border  at  its  lower  part,  at  a  spot  more  readily  kept  under  notice  if  much 
bleeding  follow. 

*  Water,  4  oz.  ;  glycerine,  4  oz. ;  borax,  2  oz.  To  be  diluted  with  water  to  i  in  10, 
or  I  in  4.  according  to  the  condition  of  the  part  syringed.  Solutions  of  carbolic  acid 
or  mei'cury  perchloride  should  be  avoided  in  such  cases,  for  fear  of  irritation  or 
absorption.     The  temperature  of  the  fluid  should  be  about  110°. 

t  Mr.  Kendal  Franks  (Ji,ancci.  1880,  vol.  ii.  p.  1223)  thus  removed,  piecemeal,  a 
friable  stone  weighing  171  grains,  and  composed  of  lime  carbonate  and  phosphates. 
In  this  case  the  urine  had  been  foetid,  though  acid.  The  wound  healed  by  first  intention. 
In  cases  of  piecemeal  removal  of  calculi,  especially  when  friable,  a  certain  amount  of 
doubt  will  often  remain  as  to  the  entire  removal. 


126  OPERATIONS  ON  THE  ABDOMEN. 

further  actual  contact  with  the  calculus  was  made  with,  the  finger  in 
the  interior  of  the  kidney." 

If  the  kidney  be  enlarged,  with  expanded  calyces,  the  result  of 
calculous  hydi'onephrosis  or  pyonephrosis,  on  searching  through  the 
pelvis  after  a  stone,  the  gush  of  fluid  and  collapse  of  the  expanded 
kidney  may  cause  the  stone  to  disappear,  and  thus  lead  to  much  trouble 
in  its  removal  (Symonds,  Clin.  Soc.  Trans.,  vol.  xviii.  p.  i8i). 

Mr.  Morris  (loc.  supra  cit.)  gives  two  other  conditions  which  ma}" 
prove  embarrassing.  "  Sometimes  in  feeling  over  the  kidney  a  portion 
of  it,  varjdng  in  size  from  a  sixpence  to  a  five-shilling  piece  or  more, 
is  found  soft,  flaccid,  thin  or  fluctuating,  and  there  is  nowhere  any  sense 
of  hardness  or  increased  resistance,  such  as  might  be  expected  from 
even  a  phosphatic  stone.  On  incising  or  puncturing  this  soft  part, 
pus  or  purulent  urine  is  drawn  off,  but  no  stone  is  felt ;  but  on  intro- 
ducing the  finger  into  the  interior  of  such  an  organ,  a  small  calculus 
may  be  detected,  freely  movable  within  an  enlarged  pelvis,  or  fixed 
in  a  dilated  calyx,  or  possibly  at  the  apex  of  a  funnel-shaped  pelvis. 
Such  cases  show  that  aspiration,  or  simple  incision  and  drainage,  are 
insufficient,  and  that  one  ought  not  to  be  satisfied  with  anything  less 
than  a  digital  examination  of  the  interior  of  the  pelvis,  of  the  calyces 
and  commencement  of  the  ureter.  Another  arrangement  of  the  calculus 
is  sometimes  found  in  sacculated  kidneys.  The  renal  cavity  may  be 
wholly  or  partially  filled  by  a  soft,  mortary,  phosphatic  calculus  which 
gives  no  sound  or  resistance  to  the  scalpel  or  trocar,  and  yet,  on  incising 
the  renal  substance  and  inserting  the  finger,  a  stone  of  considerable 
size  may  be  felt." 

One  more  difficulty,  which  must,  however,  I  think,  be  a  very  rare  one, 
is  inability  to  reach  the  pelvis  in  a  stout  patient.  Mr.  Mansell  Moullin 
relates  (Clin.  Soc.  Trans.,  vol.  xxv.  p.  57)  a  case  of  this  kind  : 

The  patient,  a  lady,  aged  about  40,  and  rather  stout,  had  suffered  for  ten  days  from 
total  suppression  of  urine,  believed,  and  correctly  so,  to  be  due  to  a  calculus  having 
blocked  the  upper  end  of  the  ureter  of  the  only  kidney  vs^hich  remained  functionally 
active.  The  left  kidney  was  explored  by  the  usual  lumbar  incision.  "  There  was  no 
difficulty  in  finding  the  kidney,  although  it  seemed  to  lie  unusually  deep.  Its  surface 
was  smooth  and  uniform,  but  very  firm,  and  it  was  not  possible,  either  by  rolling  the 
patient  on  to  her  back,  or  by  hooking  the  kidney  outwards,  to  pass  the  finger  sufficiently 
far  on  to  the  anterior  surface  to  feel  the  pelvis.  The  kidney  was  punctured  and  explored 
by  dressing-forceps  and  sound,  but  no  stone  detected.  The  operation  was  successful  in 
that  urine  soon  began  to  escape,  but  the  patient  sank  with  pyelitis  and  increasing 
asthenia  on  the  twenty-third  day.  The  necropsy  showed  no  trace  of  a  right  kidney.  The 
left  was  much  enlarged,  and  an  oval  uric-acid  calculus  was  impacted  in  the  ureter  at  its 
commencement,  lying  nearly  in  the  middle  line  of  the  body. 

If  after  free  incision  and  thorough  exploration  of  the  kidney  no  stone 
is  found,  the  ureter  must  next  be  explored  throughout  its  whole  length 
by  passing  a  No.  3  English  bougie  or  catheter  down  it  into  the  bladder. 
The  catheter  may  be  passed  through  the  incision  in  the  kidney  into  the 
ureter.  If,  however,  the  orifice  of  the  ureter  cannot  be  hit  off  in  this 
way,  Morris  advises  a  small  puncture  in  the  posterior  aspect  of  the 
infundibulum,  through  which  the  catheter  can  be  then  easily  passed 
into  the  ureter.  After  the  exploration  this  incision  can  be  closed  by  a 
catgut  suture. 

Should  a  stone  be  found  to  be  impacted  in  the  ureter,  it  must  now  be 
exposed  and   removed.     The  following  description   of  the  methods   of 


NEPHRO-LITHOTOMY.  1 27 

reaching  the  different  parts  of  the  ureter  is  chiefly  based  on  the  lines 
laid  down  by  Morris : — The  original  oblique  incision  is  prolonged  doA\'n- 
wards  and  forwards  to  a  point  one  inch  above  and  in  front  of  the 
anterior  superior  iliac  spine,  and,  if  necessary,  still  further  forwards 
towards  Poupart's  ligament,  and  then,  parallel  to  this  structure  and  one 
inch  above  it,  as  far  as  the  level  of  the  internal  abdominal  ring,  or  even 
farther.  Through  this  incision  both  the  abdominal  and  pelvic  portions 
of  the  male  ureter  can  be  exposed,  and  the  abdominal  part  and  upper 
half  of  the  pelvic  portion  in  the  female. 

Since  the  ureter  is  frequently  dilated  behind  a  stone,  after  the  calculus 
has  been  reached  with  the  finger  in  the  manner  described,  it  can 
generally  be  gradually  pushed  up  the  dilated  ureter  towards  the  kidney. 
If  possible  this  should  be  done,  for  two  reasons :  in  the  first  place,  the 
higher  in  the  ureter  the  more  accessible  will  this  structure  be  for 
removal  of  the  stone  and  suture ;  and,  secondly,  damage  to  a  portion  of 
the  ureter  already  pi'obably  inflamed  or  ulcerated  by  the  calculus  will  be 
avoided,  and  thus  more  rapid  healing  ensured. 

In  order  to  remove  the  stone  the  ureter  must  be  incised  over  it  in  a 
longitudinal  direction  with  a  sharp  tenotome.  The  wound  in  the  ureter 
is  then  immediately  closed  by  means  of  Lembert  sutures  passing  through 
the  outer  coats  only,  the  number  of  sutures  depending  on  the  size  of 
the  incision  in  the  ureter.  Incisions  made  into  the  kidney  can  usuall}' 
also  be  sutured.  When,  however,  the  kidney  substance  has  been  much 
lacerated  in  the  removal  of  a  large  calculus,  sutures  are  better  dispensed 
with.  For  incisions  into  the  infundibulum,  Lembert  sutures  of  fine 
catgut  are  employed.  Incisions  in  the  renal  parenchyma  may  be  closed 
in  the  following  manner : — Several  sutures  of  medium-sized  catgut  are 
used  (if  too  fine,  they  will  cut  through).  They  are  passed  deeply 
through  the  kidney  by  means  of  large,  fully-curved  needles,  three  to 
five  sutures  being  used,  according  to  the  size  of  the  incision. 

These  sutures  are  passed  and  tied  before  the  compression  of  the  renal 
vessels  is  relaxed,  Cumston  (loc.  sujpra  cit.)  suturing  the  kidney  before 
removal  of  the  clamp.  In  this  way  two  very  important  advantages  are 
gained — the  prevention  of  hemorrhage  from  the  kidney,  and  also  usually 
the  prevention  of  leakage  of  urine  ;  the  result  is  that  primary  union 
of  the  incisions  frequently  takes  place,  and  rapid  healing  of  the  whole 
wound  and  early  convalescence  thus  ensured. 

A  drainage-tube  or  a  strip  of  iodoform  gauze  is  now  passed  down  to 
the  kidney  or  the  incision  in  the  ureter,  in  order  to  allow  of  free 
drainage  should  leakage  of  urine  occur.  The  rest  of  the  wound  is  then 
closed,  the  muscles  being  first  brought  together  by  buried  sutures. 

If,  however,  the  kidney  has  been  much  lacerated,  or  if  for  any  other 
reason  no  sutures  are  placed  in  the  kidney,  a  full-sized  drainage-tube 
must  be  passed  down  to  the  kidney  in  order  to  allow  of  free  drainage ; 
or  if  there  is  free  oozing  the  wound  may  be  packed  with  iodoform  gauze, 
which  is  left  in  position  for  twenty-four  hours.  The  ends  only  of  the 
wound  must  be  sutured  in  this  case,  and  the  dressings  changed  as  often 
as  they  become  soaked  with  iirine. 

A  stone  may  be  missed  at  the  operation,  and  come  away  from  the 
wound,  or  be  passed  later  on  per  urethram.  An  instance  of  the  former 
is  given  by  Mr.  Bruce  Clarke  (lllus.  Med.  News,  p.  4).  The  latter  hap- 
pened to  me  in  case  No.  9  in  the  table  (p.  138). 


128  OPERATIONS  OX  THE  ABDOMEN. 

After-treatment. 

The  chief  points  here  are :  i .  The  meeting  of  shock  after  a  pro- 
longed operation.  2.  Changing  of  the  dressing  at  sufficiently  frequent 
intervals  at  first,  according  to  the  amount  of  urine  and  blood  which  soak 
through.  3.  Gradual  shortening  of  the  drainage-tube  instead  of  entire 
removal,  especially  Avhere  there  has  been  much  interference  with  the 
surrounding  parts,  or  where  pus,  &c.,  have  been  present  in  the  kidney. 
4.  Avoidance  of  all  chills.  5.  Appropriate  food,  mainly  the  blandest 
fluids  in  regulated  amounts,  especially  where  the  condition  of  the  other 
kidney  is  doubtful. 

Lastly,  it  may  be  pointed  out  that  the  life-histories  of  these  cases 
should  be  followed  up  most  carefully,  to  see  how  far  the  cure  remains  a 
complete  one ;  to  aid  this,  the  patient  should  pay  lifelong  attention  to 
his  diet,  habits,  exercise,  &c. 

Difficulties  in  Nephro-lithotomy. 

I.  An  insufficient  incision.  2.  Abundant  fat — e.g.,  in  the  sub- 
cutaneous tissues,  around  the  kidney,  and  extra-peritoneal,  rendering 
the  wound  very  deep.  3.  Rigidity,  and  perhaps  thickening,  of  the 
muscles,  due  to  the  irritation  of  the  stone.  This  condition  was  present 
in  a  very  marked  degree  in  a  patient  from  whom  I  removed  the  smaller 
calcium-oxalate  calculus  (Fig.  40).  No  amount  of  anaesthetic  seemed 
to  have  any  effect  on  this  condition.  Fortunately  the  loin  was  a  thin 
one,  and  the  stone  very  obvious  on  reaching  the  pelvis.  4.  Matting  of 
the  parts  around  the  kidney,  rendering  it  difficult  to  explore  this  organ, 
its  different  parts  and  relations,  exactly.  5.  An  indurated  condition  of 
the  kidney  itself  from  the  irritation  of  a  stone.  6.  Troublesome  flatulent 
distension  of  the  colon.  This  is  not  at  all  uncommon.  The  bowel  should 
be  packed  away  with  sponges  fastened  on  to  silk,  and  pushed  deeply 
into  the  front  of  the  wound.  7.  Opening  the  peritonaeum.  This  acci- 
dent occasionally  occurs  in  difficult  cases.  If  the  wound  be  kept  aseptic, 
there  will  be  no  serious  consequences. 

In  case  11  of  the  series  below.  I  opened  the  peritonieiini  under  the  following  circum- 
stances:  The  week  before,  in  No.  10.  the  kidney  lay  very  high  up  under  the  ribs.  In 
No.  II  it  was  placed  very  low,  closely  surrounded  by  the  colon,  and  with  its  lower  end 
in  the  left  iliac  fossa.  It  was  also  the  seat  of  a  small  hydronephrosis,  and  therefore 
soft  and  yielding.  On  slitting  up  the  lumbar  fascia  the  descending  colon  came  into 
view  with  a  soft  mass  behind  it,  which  I  took  for  pultaceous  faecal  contents.  I  accord- 
ingly explored  with  my  finger  higher  up,  and  iinder  the  ribs  found  a  body  firm  and 
fleshy,  with  a  feel  like  the  kidney,  but  too  small.  This  proved  to  be  the  spleen, 
unusually  movable.  The  opening  in  the  peritoujeum  was  kept  covered  by  aseptic 
sponges,  and  the  mass  behind  the  colon  investigated.  This  proved  to  be  the  kidney,  ex- 
tremely low  down,  and  containing  a  calculus  in  the  pelvis,  this  last  being  also  distended 
with  fluid.  For  the  first  few  days  I  kept  strips  of  sal  alembroth  gauze,  changed  two  or 
three  times  in  the  twenty-four  hours,  tucked  up  under  the  ribs,  and  stitched  the  low- 
lying  kidney  well  up  into  the  wound,  so  that  the  urine  should  escape  freely.  The 
patient  recovered  without  a  bad  symptom.  Smaller  openings  should  be  tied  up  with 
chromic  gut,  or  sutured  with  the  same. 

8.  A  stone  present,  but  very  difficult  to  detect.  This  may  be  due  to 
{a)  its  small  size,  especially  if  it  lies  deeply  in  a  calyx,  or  is  surrounded 
by  very  indurated  kidne}^  tissue.  A  ver}^  small  stone  may  cause  severe 
s^•mptoms.  This  was  proved  by  some  of  the  cases  in  the  table  given  at 
p.  138. 


XEPHRO-LITIIOTOM  Y.  1 29 

Thus,  in  Case  5,  a  stone,  weighing  but  fourteen  grains,  and  situated  in  the  top  of 
the  ureter,  quite  incapacitated  the  patient  from  any  work.  In  case  No.  8,  another 
very  small  stone,  firmly  fixed  in  a  calyx  at  the  upper  part  of  the  kidney,  caused 
severe  hsematuria  and  pain. 

The  following  case,  under  the  care  of  Dr.  Murphy,  of  Sunderland 
(Brit.  Med.  Journ.,  vol.  i.  1891,  p.  757),  shows  still  more  clearly  what 
urgent  symptoms  a  tiny  calculus  may  cause  : 

The  patient,  aged  39.  had  been  a  complete  invalid  for  nine  months,  owing  to 
repeated  attacks  of  renal  colic,  which  morphine  failed  to  relieve,  the  administration 
of  chloroform  being  frequently  required.  At  the  operation,  "a  very  small  stone 
about  the  size  of  a  hemp-seed,  escaped  with  a  flush  of  blood,"  when  the  kidney  was, 
incised.     The  site  of  the  stone  is  not  given.     A  good  recovery  followed. 

How  impossible  it  is  to  detect  some  stones,  without  incision  of  the 
kidney,  is  shown  by  a  case  published  by  Mr.  Morris  :  * 

This  authority,  with  all  his  experience,  after  thoroughly  exploring  the  kidney, 
compressing  it  aU  over  with  the  finger  and  thumb,  and  also  after  puncturing  it, 
failed  to  detect  a  stone  which  lay  in  a  hollowed-out  calyx.  Though  the  calculus 
was  the  size  of  a  small  marble,  it  was  so  thickly  surrounded  by  kidney-tissue 
that,  even  after  the  removal  of  the  kidney,  the  position  of  the  stone  could  not  be 
detected  by  pressing  on  the  kidney  with  the  fingers  as  it  lay  on  a  table.  The 
patient  made  a  good  recovery. 

(/3)  A  sacculated  kidney,  into  one  of  the  sacculi  of  which  a  small 
stone  may  fall  and  be  hard  to  find  (p.    126). 

9.  A  stone  on  the  anterior  surface  of  the  kidney,  especially  if  near 
the  entrance  of  the  vessels.  10.  A  verv  large  or  a  branchino-  stone 
(p.  125).  Mere  size  does  not  necessarily  create  difficulties  in  extrac- 
tion, though,  owing  to  the  changes  entailed  in  the  kidneys,  the  general 
health,  etc.,  by  the  long  duration  of  a  calculus,  the  prognosis  is  rendered 
very  much  less  favourable.  Thus,  in  the  calculus  (Fig.  40)  weighing 
473  grains,  or  very  nearly  an  ounce,  the  very  bulk  of  the  stone  rendered 
its  detection  easy ;  it  was  readily  loosened  from  the  luuch  dilated  pelvis 
with  lithotomy  forceps.  A  branched  calculus  presents,  of  course,  much 
greater  difficulties  (p.  125). 

Mr.  Bennett  May  has  published  QC'lin.  Soc.  Trans.,  vol.  xvi.  p.  90)  an  excellent 
instance  of  this  kind,  in  which  he  successfully  removed  a  very  largo,  somewhat 
S-shaped  calculus  from  a  man  aged  34,  with  symptoms  of  sixteen  years"  duration. 
Though  the  stone  weighed  473  grains,  and  was  three  inches  long,  manipulation 
failed  to  make  it  out  distinctly,  but  acupuncture  detected  it  at  once. 

Mr.  Footner,  of  Tunbridge  Wells,  removed  a  calculus  weighing  822  grains,  or  nearly 
two  ounces.  The  patient  made  a  good  recovery,  but  a  sinus  persisted,  through 
which,  on  two  occasions,  a  miUet-seed  calculus  was  passed  {Brit.  Med.  Journ..  1892, 
vol.  ii.  p.  69).  A  calculus  far  exceeding  the  above  was  brought  by  Mr.  D.  Day,  of 
Norwich,  before  the  Clinical  Society  QTrajis.,  vol.  xxvi.  p.  24).  This  calculus, 
mainly  phosphatic,  weighed  1331  grains.  The  patient  made  a  good  recovery,  with 
a  sinus  persisting  in  the  loins.  A  calculus  larger  than  either  of  these  is  mentioned 
at  p.  134. 

II.  A  stone  which  breaks  up  readily  (p.  125).  Another  condition 
allied  in  difficulty  is  where  a  calculous  deposit  rather  than  a  distinct 
calculus  is  present.     This  is  more  grave,  as  the  deposit  here  will  usually 

*  Med.-C'hir.  Trans.,  vol.  xlviii.  p.  6g.  The  woodcut  (p.  73)  shows  well  the  relation 
of  the  stone  to  the  surrounding  kidney. 

VOL.   II.  9 


130  OPERATIONS  ON  THE  ABDOMEN. 

be  phosphatic,  and  point  to  co-existing  pyo-nephrosis.  12.  Multiple 
calculi.  Stones  (usually  minute  in  size)  numbering  over  60 
or  100,  have  been  removed  on  several  occasions.  In  such  cases 
it  is  always  possible  that  the  minute  calculi  have  been  retained, 
owing  to  a  larger  calculus — e.g.,  in  the  pelvis  or  ureter — block- 
ing their  exit.  13.  A  very  mobile  kidney.  The  importance  of 
having  an  assistant  to  push  the  kidney  well  up  into  the  wound  has 
already  been  insisted  on.  It  is  essential  to  have  this  done  both  for 
detection  of  the  stone  and  for  its  removal,  in  order  to  avoid  needless 
disturbance  of  the  surrounding  parts,  or  the  kidney  may  be  secured 
with  sutures  at  the  commencement. 

Mr.  May  Qog.  svpra  cit.')  explains  the  remarkable  fact  that  his  large  stone  was 
not  felt  when  the  kidney  was  thoroughly  exposed,  by  the  fact  that  the  organ  fell 
forwards  and  thus  embarrassingly  increased  the  depth  of  the  wound. 

14.  A  kidney  situated  very  high  up  under  the  ribs  (p.  128).  15.  A 
kidney,  the  pelvis  of  which  it  is  difficult  to  reach  owing  to  the  stoutness 
of  the  patient,  as  in  the  case  given  at  p.  I  26. 

Question  of  Nephrectomy  during  a  Nephro-lithotomy. — In  several 
of  the  above  conditions  the  question  of  the  advisability  of  removal  of  the 
kidney  will  arise — e.g.,  where  the  kidney  has  been  much  handled  and 
repeatedly  incised,  Avhere  the  stone  is  large  and  branched  and  difficult  of 
removal,  where  many  stones  are  present,  or  where  one  is  present  and 
very  friable,  where  the  kidney  is  much  altered  by  pyo-  or  hydro- 
nephrosis, and,  finally,  where  the  surgeon  is  certain  a  stone  exists  but 
cannot  find  it,  as  in  Mr.  Morris's  case  already  alluded  to  at  p.  129. 

In  such  cases  the  surgeon  will  be  guided  by  the  age  of  the  patient ; 
the  knowledge  he  possesses  as  to  the  condition  of  the  other  kidney 
(the  amount  of  urine,  the  percentage  of  urea,  etc.)  ;  the  degree  to  which 
the  kidney  he  is  operating  on  has  been  disturbed  from  its  relations,  and 
its  structure  interfered  with  ;  the  amount  of  disease,  e.g.,  number  of 
sacculi,  condition  of  pus  contained  in  them,  the  thinning  of  the  cortex, 
etc.  When  the  surgeon  is  certain,  from  the  history  and  failure  of 
previous  treatment,  that  a  stone  exists  which  cannot  be  found,  he  must 
he  chiefly  guided  by  the  degree  to  which  life  has  been  made  miserable. 
Finally,  the  length  of  time  that  the  operation  of  nephro-lithotomy  has 
already  lasted,  and  the  condition  of  the  patient,  must  be  taken  into 
account.  Where  the  patient  is  young,  where  the  other  kidney  is 
healthy,  where  the  kidney  operated  on  is  much  damaged  either  b}^ 
previous  disease  or  by  manipulation  added  to  disease,  where  several 
stones  are  present,  nephrectomy,  either  now,  or  a  little  later,  is  indi- 
cated ;  of  these,  immediate  removal  of  the  kidney  is  preferable  if  the 
patient's  condition  admits  of  it.*  But  the  question  is  a  very  different 
one  where  the  kidney  is  a  large  one  after  its  fluid  contents  as  well  as 

♦  An  instructive  case  which  was  under  my  care  illustrates  well  many  of  the  above 
difficulties — viz.,  multiple  and  large  calculi,  a  mobile  kidney,  the  question  of 
nephrectomy  arising  during  nephro-lithotomy,  and  the  formation  of  multiple  calculi 
in  one  kidney  without  symptoms.  In  February  1888  I  was  asked  by  Dr.  Goodhart 
to  see  a  case  of  probable  renal  calculus.  The  boy,  aged  15,  had  been  admitted  with 
abdominal  pain  and  grating  of  an  indistinct  and  delicate  nature  in  the  left  renal 
region.  This  kidney  was  slightly  enlarged.  When  asked  to  localise  his  pain,  the 
patient  pointed  to  the  region  of  the  left  kidney  and  the  hift  loin.  This  kidney 
being  explored  was   found  to  be  occupied  by  irregular  nodulated  masses.      A  hare- 


NEPHRO-LITIIOTOMY.  131 

a  stone  have  been  removed ;  or  where  it  is  a  case  of  multiple  calculi  in 
a  suppurating,  damaged  kidney.  Nephrectomy  should,  as  a  rule,  be 
deferred  here,  and  the  kidney  thoroughly  drained,  for  (i)  additional 
shock  and  loss  of  blood  will  be  avoided.  (2)  The  condition  of  the 
opposite  kidney,  very  possibly  calculous  also,  will  be  made  clearer  by 
waiting.  (3)  The  bulk  of  the  kidney  will  be  lessened  by  drainage. 
(4)  Though  a  source  of  discomfort  (if  an  open  sinus  persist)  it  may  still 
do  some  and  important  work. 

Causes  of  Death  after  Nephro-lithotomy. — Very  few  iinsuccessful 
cases  have  been  published  ;  the  following  appear  to  be  most  probable 
causes  of  after-trouble : 

I.  Hasmorrhage.  A  most  interesting  case  of  haemorrhage,  fatal  on 
the  seventh  day  after  nephro-lithotomy,  was  brought  before  the  Clinical 
Society  (Trans.,  vol.  xxii.  p.  214),  by  Dr.  Stevenson  and  Mr.  Butler 
Smythe : 

Several  small  and  one  larger  stone  (this  one  being  tightly  fixed  in  the  pelvis  and 
ureter)  having  been  removed  from  a  kidney,  the  site  of  hydro-nephrosis,  the  patient 
did  well,  save  for  a  temperature  which  was  103^  on  the  third  and  fifth  days  and 
all  along  very  variable,  until  the  sixth  day,  when  bright  blood  and  urine  were 
passed  both  by  the  urethra  and  by  the  wound.  On  the  seventh  day  about  haK  a 
pint  of  bright  bloody  urine  was  drawn  off  from  the  bladder,  and  death  took  place 
:Soon  after,  with  symptoms  of  internal  h«morrhage.  The  kidney  was  found  enor- 
jnously  distended  with  blood-clot  and  bloody  urine.  The  opening  made  at  the 
■operation  was  small  and  blocked  up  by  clot.  Embedded  in  the  kidney  substance, 
close  to  the  pelvis,  was  a  round  spiked  calculus,  which  had  ulcerated  into  a  branch 
of  the  renal  artery  just  at  its  entrance  into  the  kidney,  and  had  given  rise  to 
profuse  bleeding  into  this  dilated  organ. 

lip  pin  at  once  came  on  and  between  calculi.  The  kidney  being  incised,  hosts  of 
calculi,  comparable  only  to  a  gravel-pit,  were  found  in  the  calyces  and  pelvis,  the 
chief  nests  being  at  the  upper  and  lower  extremities.  The  former  of  these,  lying 
as  they  did  high  up  under  the  ribs,  gave  much  trouble.  To  get  at  them  the  kidney- 
tissue  was  again  scraped  through  directly  over  them,  and  many  of  them  thus  reached. 
The  chief  difficulty  of  the  operation,  in  addition  to  the  number  of  stones,  was  the 
great  mobility  of  the  kidney,  though  this  organ  was  well  pushed  up  from  the  front. 
The  condition  was  perhaps  due  to  the  almost  entire  absence  of  surrounding  fat. 
When  I  realised  the  condition  of  the  kidney,  I  expressed  myself  in  favour  of 
nephrectomy,  as  the  organ  was  almost  useless,  as  the  stones  were  so  numerous,  and 
as  a  prolonged  attempt  at  removal  would  produce  more  shock  in  so  weakly  a 
subject.  One  or  two  less  important  points  in  favour  of  nephrectomy  were  the 
mobility  of  the  kidney  and  the  entire  absence  of  adhesions.  Dr.  Goodhart's  counsel 
was,  however,  against  this  step,  owing  to  the  small  percentage  of  urea— this  had 
never  been  above  i'2  per  cent.,  and  often  less.  I  accordingly  continued;  when 
forty-six  calculi  had  been  removed  and  the  operation  had  lasted  three-quarters  of 
an  hour,  the  pulse  failed  so  ominously  that  I  was  obliged  to  desist.  Very  little 
blood  escaped  as  long  as  the  opening  was  plugged  with  the  finger,  but  considerable 
.oozing  followed  as  the  finger  brought  out  the  stones.  The  patient  never  rallied 
well,  and  died  three  hours  and  a  half  after  the  operation.  The  necropsy  showed  a 
little  ecchymosis  around  the  left  kidney ;  this  still  contained  calculi  at  its  upper 
and  lower  parts.  The  rifjlit  kidney,  of  which  the  boy  had  never  complained,  also 
contained  a  large  number  of  stones.  Its  substance,  though  much  wasted.  stiU  con- 
tained a  fair  amount  of  secreting  substance.  The  condition  of  the  opposite  kidney 
thus  abundantly  justified  my  old  friend's  opinion.  Feeling  that  unsuccessful  cases 
of  nephro-lithotomy  have  not  been  sufficiently  published,  I  brought  this  and  the 
.case  at  page  132  before  the  Clinical  Society.  A  detailed  account  of  each  will  be 
found,  with  ten  others,  in  the  Tranmctions,  vols.  xxii.  p.  198,  and  xxiv.  p.  155. 


132  OPERATIONS  ON  THE  ABDOMEN. 

The  following  possible  causes  of  haemorrhage  after  nephro-lithotomy 
must  also  be  remembered  : 

In  case  No.  ig  in  the  table,  p.  139,  the  patient  was  a  young  Welsh  miner,  with 
all  the  symptoms  of  renal  calculus  well  marked.  At  the  operation  two  calculi  were- 
easily  found  and  removed  from  the  lower  part  of  the  right  kidney.  About  three- 
hours  after  the  operation  the  usual  soakage  of  urine  had  taken  place  through  the 
dressings  ;  but  it  was  noticed  to  be  unusually  brightly  stained  with  blood.  When 
the  dressings  were  removed  blood  was  seen  to  be  trickling  through  the  tube  which 
I  had  left  in  contact  with  the  wound  made  in  the  lower  part  of  the  outer  border 
of  the  kidney.  Dr.  Bligh,  now  of  Caterham  Valley,  and  then  house-surgeon,  plugged 
the  wound,  and,  the  patient  passing  into  a  state  of  collapse,  resorted  to  saline 
infusion.  On  my  arrival  at  this  time,  I  found  that  the  patient  had  partially 
rallied.  Similar  bleeding  followed  about  two  hours  later,  the  wound  was  replugged, 
and  transfusion  again  resorted  to  ;  but  the  patient  sank  seventeen  hours  after  the 
operation.  At  the  necropsy  nothing  was  found  in  the  wound  beyond  some  coagula 
and  ecchymosis  round  the  kidney,  and  a  very  small  calculus,  which  I  had  over- 
looked when  the  two  others  were  removed.  There  was  marked  contraction  of  the 
mitral  valve.  It  is  very  difficult  to  estimate  the  loss  of  blood  in  such  a  case,  but 
it  was  thought  not  to  exceed  six  or  seven  ounces,  and  there  were  no  coagula.  The 
operation  was  of  the  simplest  kind,  but  the  marked  pallor  of  the  patient's  face 
ought  to  have  led  me  to  inquire  for  a  cause  beyond  that  which  I  too  readily  took 
for  granted,  viz.,  the  pain,  etc.,  set  up  by  the  renal  calculi.  I  am  not  aware  of 
any  case  that  has  been  published  in  which  surgical  hsemorrhage  has  been  asso- 
ciated with  a  contracted  mitral  valve,  but  I  have  been  given  to  understand  that 
parturient  women  with  the  above  lesion  are  especially  liable  to  the  peril  of  flooding. 

Another  possible  cause  of  hasmorrhage  after  nephro-lithotomy  is 
where  calculi  are  associated  with  a  growth  in  the  pelvis  of  the  kidney. 
Mr.  Battle  has  recorded  a  most  interesting  instance  of  this  (Brit. 
Med.   Journ.  Yo\.  i.    1895,  p.    1206): 

At  a  lumbar  nephro-lithotomy  several  oxalate  calculi  were  removed  and  a  villous 
growth  scraped  away  from  the  lower  anterior  aspect  of  the  pelvis.  The  patient 
resumed  work,  but  the  hsematuria  returned  and  became  profuse  and  constant,  and 
the  kidney  was  removed  about  eighteen  mouths  after  the  first  operation.  The  surface 
about  the  pelvis  was  papillated  and  firm,  and  the  microscope  showed  evidence  of  a 
new  growth  at  this  spot,  but  whether  this  was  a  simple  papilloma  or  a  squamous 
epithelioma  remained  doubtful. 

2.  Cellulitis.  If  it  has  been  needful  to  incise  or  tear  the  kidney 
freely,  if  the  urine  is  foul,  and  the  bleeding  has  been  arrested  with 
difficulty  after  imperfect  and  repeated  plugging,  this  may  be  readily 
brought  on.  Other  causes  of  this  will  be  found  in  much  disturbance 
of  the  wound  or  fingering  by  many  hands. 

3.  Ureemia,  if  the  other  kidney  is  the  site  of  calculous  disease  or 
disorganised.  This  was  chiefly  the  cause  of  death  in  the  case  in 
which  I  removed  the  large  stone  (Fig.  40). 

The  patient  was  a  solicitor,  aged  58,  of  sedentary  life,  and  gouty  history,  who  had 
suffered  from  attacks  of  right  renal  colic  ofE   and  on  for  upwards  of  thirty  years,* 

*This  long  duration  of  symptoms  was  unfavourable.  Mr.  Keetley  was  more 
fortunate  in  a  case  equally  long  standing,  in  a  much  younger  patient  CBrit.  Med. 
Journ.,  vol.  i.  1890,  p.  134.  A  gentleman,  aged  44,  for  thirty  years  had  not  passed 
twenty-four  consecutive  hours  without  pain.  Mr.  Keetley  removed  150  calculi  from 
the  right  kidney.  A  large  rough  calculus  had  blocked  the  way  into  the  ureter  for 
the  numerous  smooth  calculi  which  formed  behind  it.  The  patient  made  a  good 
recovery. 


NEPHRO-LITHOTOMY. 


133 


these  attacks  having  become  increasingly  fierce  for  about  six  months.     Occasionally 

he  had  had  slight  pain  on  the  left  side,  and  on  the  morning  fixed  for  the  operation 

he  passed  two  small,  fawn-coloured  calculi  of  lithic  acid  and  lithates.     These  were 

■quite   insuflficieut   to   account   for   all   his   suffering,   and   as   prolonged   and  careful 

treatment  had  entirely  failed,  and  as  his  "  life  was  not  worth  having  at  the  price," 

the  operation  was  proceeded  with,  and 

the    huge    renal    calculus    figured  re-  Fio.  40. 

moved.      This   was   effected   with   the 

utmost   ease,   as   the    stone,   from  its 

size  and  hardness,  was  readily  detected 

occupying  the  distended  pelvis  of  the 

kidney.     A  profuse  jet  of  venous  blood 

followed   its  removal  with   lithotomy 

forceps,  after  it  had  been  loosened  by 

a,  scooping  movement   of    the  finger. 

The  haemorrhage  was  at  once  arrested 

by  sponge-pressure  kept  up  for  a  few 

minutes.     All  went  well  for   the  first 

week,    save    for   persistent    oxaluria. 

which    no    treatment    could    remove. 

The   patient  was  able   to  sit  up  and 

read ;    appetite     returned,    and    the  ,                    , .       -,  1 

J               IT              11        ,-w       4.1,  The  larger  calculus  IS  the  one  mentioned  here 

vs-ound    was    healing    well.      On    the  ,                 -r.       •  1    j                     i          ■  >■  a  ^t 

.    „     ,                 ,               ^         .,  in  the  text.     It  weighed  473  gr.,  and  consisted  of 

sixth  dav   a    change    for    the  worse  ,..,.        .,       ^  i-i.i  „<.„„      ti^o  ,.io;„  ,-,io==  la-ir  I'n 

'                   °  lithie  acid  and  lithates.      the  mam  mass  lay  m 

set  in,  first  much  flatulence  and  nausea,  ^j^^  ^^j^^^^  p^l^ig^  tl^e  processes  fitted  into  the 
then  constant  restlessness,  followed  by  ealyces.  The  smaller  calculus,  composed  chiefly 
«oma,  ending  in  death  on  the  morn-  ^f  oxalates,  was  successfully  removed  from  a 
ing  of  the  eighth  day.  I  cannot  patient  aged  24.  It  weighed  42  grs.  The  two 
doubt  that  the  opposite  kidney  was  are  good  instances  of  what  nephro-lithotomy 
here  also  the  seat  of  stone,  and  its  can,  and  what  it  cannot  do,  without  grave 
tissue  too  much  impaired  to  admit  risks, 
of  recovery,  though    I  was   unable  to 

obtain  a  post-mortem  examination  to  verify  this.  I  should  add  that  the  urine  in 
this  patient  before  the  operation  was  acid,  of  sp.  gr.  1018,  and  without  sugar  or 
albumen.  The  quantity  passed  was  natural,  and  the  urea  sometimes  normal,  some- 
times slightly  deficient. 

Dr.  Whipham  and  Mr.  Haward  {Clin.  Soc.  Trans.,  vol.  xv.  p.  123) 
have  recorded  a  case  which,  with  my  own  just  given,  points  urgently 
to  the  importance  of  surgeons  being  permitted  to  explore  earlier : 

The  patient,  aged  56,  had  for  "  several  years "  been  troubled  with  "  graveL"  The 
symptoms  here  were  chiefly  indicative  of  calculous  mischief  in  the  left  kidney,  but 
there  was  some  tenderness  on  the  right  side  as  well.  The  urine  here  was  1006  sp.  gr., 
alkaline,  and  contained  pus.  The  left  kidney  was  explored,  and  found  in  a  state  of 
pyo-nephrosis  ;  no  calculus  was  found,  but  a  copious  discharge  of  pus  took  place  soon 
afterwards,  giving  great  relief.  The  patient  a  little  later  again  lost  ground,  and  the 
wound  was  thoroughly  explored  a  second  time,  but  the  patient  sank  a  few  hours 
after  this,  a  month  after  the  first  operation.  The  left  kidney-pelvis  was  much 
dilated  in  its  upper  part,  and  communicated  with  a  large  peri-nephritic  abscess. 
The  right  kidney  contained  a  large  branching  calculus. 

4,  Septicaemia.  This  condition  may  be  induced  by  the  wound 
becoming  foul,  a  complication  which  can  always  be  prevented  after 
removal  of  small  stones  from  healthy  kidneys.  But  where  pyo- 
nephrosis exists,  it  may  be  impossible  to  keep  the  wound  sweet  from 
the  first.     This  was  so  in  Case  6  of  the  subjoined  table. 

Here,  after  removal  of  nine  calculi,  I  was  obliged  to  remove  the  kidney  a  year 
later,  owing  to  the  persistence  of  a  foetid  sinus. 


134  OPERATIONS  ON  THE  ABDOMEN. 

And  it  is  to  be  noted  that  septicaemia  may  occur  after  a  nephro' 
lithotomy,  successful  as  far  as  the  removal  of  the  stone  goes,  after 
a  considerable  interval,  where  pyo-nephrosis  coexists.  This  is  an 
additional  reason  for  carefully  considering  the  advisability  of  perform- 
ing nephrectomy  in  such  cases. 

Dr.  Shepherd,  of  Montreal,  has  published*  a  very  interesting 
instance  of  this  kind : 

Nephro-lithotomy  was  performed  in  a  patient  aged  26,  who  had  suffered  from 
symptoms  of  stone  for  seven  years,  with  no  tumour,  and  pus  in  the  urine.  An 
enormous,  unbreakable  stone  of  triple  phosphate  was  removed  with  much  difficulty 
from  the  left  kidney.  It  weighed  4  oz.  7  dr.,  and  measured  3^  inches  in  length  and 
9  inches  in  circumference.  The  tissue  of  the  lower  part  of  the  kidney  exposed 
seemed  healthy,  and  no  pus  being  evacuated  it  was  thought  best  not  to  remove  the 
organ.  The  wound  continued  to  discharge  pus,  and  the  temperature  varied  corre- 
spondingly for  three  months  and  a  half  after  the  operation,  when  septicEemia  set  in 
and  proved  fatal.  The  necropsy  showed  that  the  upper  part  of  the  kidney,  which 
was  not  exposed,  consisted  of  large  communicating  sacs,  containing  over  10  oz, 
of  fetid  pus,  and  a  number  of  irregular  branched  calculi.  Dr.  Shepherd  points  out 
that  the  fatal  septicfemia  was  undoubtedly  due  to  these  abscesses,  showing  the  need 
of  thorough  exploration  in  all  cases  where  a  large  stone  has  set  up  grave  changes, 
and  of  extirpation  in  most  of  them. 

I  have  described  lumbar  nephro-lithotomy  fully  because  I  believe 
that,  on  the  whole,  it  is  much  the  safer  operation  for  the  great 
majority  of  operators.  But,  to  make  the  account  complete,  reference 
must  be  made  to  the  proposal  that  abdominal  should  replace  lumbar 
nephro-lithotomy. 

As  might  be  expected,  this  proposal  lias  come  from  a  specialist  in 
abdominal  surgery.  Mr.  K.  Thornton  (Harveian  Lectures,  "  Surgery 
of  the  Kidneys,"  p.  34)  gives  the  following  reasons  for  preferring  his 
combined  method:  "Recognising  the  difficulty  in  the  diagnosis  of  a 
stone,  and  the  still  further  complication  introduced  by  the  transference 
of  pain  in  some  cases  to  the  opposite  side,  and  the  importance  of 
being  able  to  examine  the  other  kidney  and  both  ureters  thoroughly, 
throughout  their  whole  course,  I  proposed  to  open  the  abdomen  by 
Langenbiich's  incision  over  the  suspected  kidney,  examine  carefully 
both  kidneys  and  ureters,  and,  having  found  a  stone,  to  employ  one 
hand  in  the  peritonaeum  to  fix  the  kidney  and  stone,  and  guard  the 
colon,  while  with  the  other  I  could  cut  down  upon  the  stone  directly 
from  the  loin,  merely  making  an  opening  through  the  loin  tissues 
large  enough  to  introduce  the  finger  and  necessary  forceps  for  the 
extraction  of  the  stone."  And  again,  at  p.  36  :  "  We  are  certain  that 
the  patient  has  the  usual  allowance  of  kidnej^s.  The  chances  of 
overlooking  the  stone,  if  there  is  one  present  in  either  kidney,  is 
reduced  to  a  minimum.  I  do  not  say  that  the  abdominal  handling 
is  absolutely  infallible,  but  in  fourteen  operations  I  have  only  once 
failed  to  find  a  stone,  and  the  recovery  and  present  health  of  this  one 
patient  make  it  highly  improbable  that  there  was,  or  is,  a  stone  in 
her  kidney.  This  result  compares  very  favourably  with  the  large 
number  of  unsuccessful  lumbar  explorations  already  recorded." 

•  Philadelphia  JVews,  April  23,  1887  ;  Annals  of  Surgery,  vol.  vi.  August  1887,  p.  185, 
The  right  kidney  is  stated  to  have  been  perfectly  healthy,  but  double  its  normal  size. 


NEPHRO-LITHOTOMY.  135 

No  one  who  has  seen  much  of  lumbar  nephro-lithotomy  would  allow 
the  above  remarks  to  pass  uncriticised. 

While  I  am  fully  aware  of  the  difficulties  in  determining  whether 
a  stone  is  present,  and  in  what  part  of  the  kidney  it  lies,  I  am 
convinced  that  every  year  that  goes  by  will  perfect  our  power  of 
diagnosis,  by  making  clearer  to  us  the  conditions  that  simulate  stone. 
"The  large  number  of  unsuccessful  lumbar  explorations"  of  which 
Mr.  Thornton  makes  a  strong  point  is  not  quite  correctly  referred 
to  by  him.  He  implies  that  a  stone  was  there,  but  that  operators 
making  use  of  lumbar  nephro-lithotomy  failed  to  find  it.  Now  this 
is  not  quite  the  case.  In  the  great  majority  of  cases  no  stone  was 
present.  They  were  cases  in  which  the  diagnosis  was  at  fault.  It 
has  always  been  so  with  every  new  operation,  and  is  one  of  those 
faults  which  time  alone  puts  straight.  In  reality,  these  failures  to 
find  a  stone  are  rather  creditable  to  the  lumbar  operation.  The 
operators  have  been  of  the  most  vaiying  degrees  of  experience,  and 
the  great  majority  of  their  cases*  have  recovered.  Would  this  have 
been  the  case  if  the  explorations  had  been  through  the  peritoneal 
cavity  with  "  the  necessary  manipulations  to  examine  the  kidneys  and 
ureters "  ?  Now,  on  this  hangs  one  of  my  chief  points.  No  one 
who  knows  anything  of  what  Mr.  Thornton  has  done  for  abdominal 
surgery  will  doubt  for  a  moment  that  operations  on  the  kidney 
through  the  peritonaeum  are  certain  to  be  as  safe  in  his  hands  as  any 
such  operation  can  be.  But  what  this  book  has  to  try  and  teach  is 
what  operation  is  the  safest  for  the  largest  number  of  operators.  I 
cannot  agree  with  Mr.  Thornton  that  the  increased  risk  due  to  the 
opening  of  the  peritona3um  is  practically  nil— i.e.,  if  the  surgeon 
Avill  take  the  pains  to  perform  a  thoroughly  aseptic  operation.  I 
should  agree  that  the  risk  of  peritonitis  is  now  much  smaller  than  it 
was,  but  there  are  other  risks  which  are  inseparable  from  this  mode 
of  exploring  the  kidney.f  1  refer  to  the  shock  which  the  necessary 
manipulations  of  certain  very  vital  parts  must  entail.  Mr.  Thornton 
will  be  able  to  go  straight  to  the  kidneys  with  a  minimum  of 
disturbance  of  the  overlying  parts.  But  is  it  to  be  believed  for  a 
moment  that  this  would  be  the  case  with  the  majority  of  opera- 
tors? And  this  brings  me  to  another  point.  Others  who  haAe 
tried  this  method  have  not  found  it  so  easy  to  detect  the  presence  ()f 
a  renal  calculus  or  to  determine  the  condition  of  the  kidneys.  "With 
regard  to  the  latter  point,  I  may  mention  the  following : 

A  woman  was  seat  to  me  with  long-standing  pyuria  of  renal  origin.  She  was 
clearly  very  near  her  end  from  kidney  failure,  and  during  the  five  days  she  lived 

*  I  have  pointed  out  (p.  131)  that  there  is  reason  to  fear  that  fatal  cases  have  not 
been  published.     But  this  would  not  apply  to  the  lumbar  operation  only. 

t  Every  one  who  has  seen  much  of  renal  surgery  will  know  that  grave  shocks  may 
readily  be  met  with  in  some  of  these  explorations  of  the  kidney.  Thus,  in  the  case 
of  nephro-lithotomy  (No.  12  in  the  table,  p.  138)  in  a  lady  of  40,  with  fifteen  years' 
history,  from  whom  I  removed  three  cystine  calculi,  the  patient  was  so  ansemic  and 
unhealthy  from  her  long-continued  pain  and  marred  life,  that  she  nearly  succumbed 
during  the  operation.  Yet  this  was  of  the  simplest,  the  loin  thin,  the  calculi  (3S7  gr.) 
found  at  once  and  extracted  easily,  the  operation  itself  not  exceeding  twelve  minutes. 
A.C.E.  followed  by  ether  had  been  given,  but  the  pulse,  always  weak,  became  almost; 
imperceptible  after  the  first  incision. 


136  OPERATIONS  OX  THE  ABDOMEN. 

no  operation  was  admissible.  After  lier  death  I  thought  it  a  good  opportunity  to 
investigate  the  condition  of  the  kidneys  by  an  abdominal  incision.  I  was  able  to 
feel  that  there  was  a  right  kidney,  which  felt  so  hard  that  I  thought  it  contained  a 
stone.  About  the  condition  of  the  left  kidney  I  was  quite  unable  to  satisfy  myself. 
The  necropsy  showed  that  the  right  kidney  was  in  a  condition  of  fibroid  atrophy  ; 
no  stone  was  present.  The  left  was  a  thin-walled  sac  containing  pus.  Owing  to  the 
great  tenderness  on  this  side,  I  had  looked  on  this  kidney  as  the  source  of  the  pyuria. 
It  would  have  been  readily  reached  from  the  loin. 

I  have  onl}^  once  tried  to  detect  a  renal  calculus  through  an 
abdominal  incision. 

The  case  was  No.  21  in  the  table  at  p.  139.  As,  in  addition  to  the  renal  symptoms, 
there  was  trouble  indicating  oophorectomy,  I  took  the  occasion,  after  Dr.  Galabin 
had  removed  the  ovaries,  to  explore  the  left  kidney,  where  the  presence  of  a  stone 
was  suspected.  The  existence  of  a  calculus,  which  felt  a  large  one — in  reality,  three 
were  present — and  of  a  small  hydro-uephrosis  could  be  made  out,  conditions  which 
were  verified  at  the  time  of  the  nephro-lithotomy  a  little  later. 

In  this  case  the  kidney  was  not  enlarged,  of  the  ordinary  firm 
consistence,  save  near  the  pelvis,  and  free  from  the  results  of  past 
inflammation.  In  such  cases  as  these  it  will  always  be  easy  to 
detect  the  presence  of  the  stone,  but  it  will  be  very  different  in 
those  cases  where  the  stone  lies  in  an  enlarged  kidney,  the  seat  of 
a  collection  of  fluid,  or  in  one  matted  down  with  much  thickening 
of  surrounding  tissues  from  long-standing  inflammation. 

But  I  would  rather  quote  the  opinions  of  others.  Mr.  T.  Smith 
(Discussion  at  the  Clinical  Society,  By-it.  Med.  Journ.,  1887,  vol.  i. 
p.  393)  said  that  Mr.  Thornton  had  seemed  to  represent  that  by  open- 
ing the  abdomen  from  the  front  one  could  ascertain  with  certainty 
whether  there  was  a  stone  in  the  one  or  other  kidney.  But  one  could 
not  always  tell  this  even  if  one  felt  the  kidnej^  out  of  the  body.  In 
three  different  cases  in  which  he  had  handled  kidneys  so  removed  no 
stone  could  be  detected  therein  until  the  kidneys  were  cut  open.* 
Another  very  interesting  case,  brought  by  Mr.  Page  before  the  Medico- 
Chirurgical  Society  {Brit.  Med.  Journ.,  1888,  vol.  i.  p.  795)  shows  what 
care  is  needed  when  abdominal  exploration  for  the  examination  of  the 
kidneys  is  made  use  of. 

Mr.  Page  thought  that  in  this  case  abdominal  exploration,  had  he  made  it,  would 
probably  have  led  him  astray,  as  the  left  kidney,  which,  though  small,  was  the 
working  one,  would  have  been  removed,  while  the  right  viscus,  which  was  really 
the  seat  of  pyelitis  and  contained  some  small  stones,  would  have  been  looked  upon 
as  merely  enlarged  to  do  the  work  of  two,  this  increase  in  size  being  really  due  to 
its  diseased  condition. 

Mr.  K.  Thornton  (p.  37)  mentions  a  case  in  which  it  took  an  hour  to 
find  the  kidne}^  by  the  lumbar  incision,  and  which  ended  fatally,  and 
another  in  Avhich  the  surgeon  failed  entirely  to  find  the  kidney  by  the 
same  method.  Such  cases,  as  shown  by  their  number,  are  quite 
exceptional.  When  the  large  number  of  explorations  of  the  kidney 
by  the  lumbar  method  is  considered,  it  will  be  acknowledged  that  the 
lumbar  method  is  characterised  by  the  ease  with  which  the  kidney  is 
found,  and  the  well-doing  of  the  cases  afterwards,  especially  when  the 
great  number  and  the  diversity  of  operators  are  considered. 

With  regard  to  pain  in   one  loin  due  to  mischief  in  the  opposite 

*  On  this  point  see  Mr.  Morris's  case,  p.  129, 


NEPHRO-LITHOTOMY.  1 37 

Ividney,  we  have  very  little  knowledge  as  to  sympathy  between  the 
kidneys.  But  this  condition  is  certainly  rare.  As  a  rule,  in  renal 
calculus,  pain  is  alone  complained  of  on  the  side  in  which  the  stone  lies. 
Pain  in  both  loins  means  usualh'  stones  or  disease  on  both  sides,  a  far 
graver  thing  than  "  sympathy." 

Mr.  Thornton,  in  his  combined  method,  which  I  have  described  at 
p.  134,  lays  stress  upon  the  small  clean  cut  which  is  made  upon  the 
stone  by  the  loin,  only  large  enough  to  introduce  the  finger  and  forceps. 
It  is  difficult  to  see  how  such  an  opening  would  suffice  to  remove  a 
small  stone  lying  in  a  calyx  on  the  anterior  surface  of  the  kidney,  one 
•of  the  most  difficult  of  all  cases.  By  the  lumbar  operation  the  surgeon 
would  be  able,  after  freeing  the  kidney,  as  is  nearly  always  feasible,  to 
luring  it  out  of  the  wound  on  to  the  loin,  and  carefully  handle  the 
anterior  as  well  as  the  posterior  surface.  With  regard  to  the  risk  of 
the  hernia  which  Mr.  Thornton  states  (loc.  supra  cit.)  to  be  "a  not 
Tincommon  result  of  the  lumbar  operation,"  the  experience  of  most 
surgeons  will  be  quite  the  opposite.  As  already  stated  (p.  103),  the 
tissues  in  the  lumbar  region  are  so  strong  and  unjaelding,  compared 
with  those  in  the  anterior  abdominal  wall,  that  a  protrusion  does  not 
readily  talve  place  here. 

Exploration  of  Kidney  in  Suppression  of  Urine. — The  above 
•condition  is  so  grave  when  a  mechanical  cause  which  medicine  can 
•avail  nothing  is  present,  the  history  may  be  so  obscure  or  perplexing, 
the  call  for  help  so  urgent,  that  some  allusion  must  be  made  to  the 
subject  here.  One  of  the  most  brilliant  examples  of  what  nephro- 
lithotomy can  do  in  some  cases  of  suppression  of  ui'ine  is  shown  by 
a  case  brought  by  Mr.  R.  C.  Lucas  before  the  Medico-Chu-urgical 
Society  (Trans.,  vol.  Ixxiv.  p.  129)  : 

The  patient,  aged  37,  had  had  her  right  kidney,  a  "  mere  shell,  containing  masses 
of  stone  weighing  twenty-one  ounces"  successfully  removed.  Three  months  later 
she  was  seized  with  agonising  pain  in  the  back  and  left  loin.  Suppression  of  urine 
quickly  set  in,  and  ou  the  fifth  day  a  calculus  was  remored  which  was  exactly  of 
the  shape  to  act  as  a  ball-valve  to  the  top  of  the  left  ureter.  The  patient  made 
an  excellent  recovery. 

But  in  many  cases  of  suppression  the  indications  are  less  clear,  and 
there  is  often  much  difficulty  in  deciding  which  ureter  is  blocked,  owing 
to  the  deficient  history.  An  excellent  instance  of  such  cases,  in  which 
the  surrounding  difficulties  wex'e  most  successfully  met,  is  recorded  by 
Dr.  Fraser  and  Mr.  Parkin,  of  Hull  (Lancet,  vol.  ii.  1893,  p.  688) : 

The  patient  here  suffering  from  suppression  of  urine  was  74  years  of  age.  Beyond 
the  evidence  pointing  to  obstructive  anuria,  there  was  very  little  to  throw  light  on 
the  condition  of  the  kidneys,  or  which  organ  should  be  explored.  As  the  patient 
liad  been  observed  by  her  friends  to  support  the  left  side  in  walking,  and  as  there 
was  deep-seated  tenderness  in  this  loin,  Mr.  Parkin  explored  the  left  kidney  from 
the  loin.  The  organ  was  enlarged,  distended,  and  hypertrophied.  About  six  ounces 
of  urine  escaped  when  the  kidnej'  was  incised  along  its  convex  border,  the  last 
portion  to  come  away  being  mixed  with  some  pus.  No  stone  was  found,  and  the 
cause  of  the  suppression  must  remain  obscure,  as  tlie  patient,  though  74,  made  a 
good  recover}',  with  a  sinus  from  which  most  of  the  urine  passed. 

The  above  cases  show  the  importance  of  knowing  the  history  of  the 
case,  and,  where  this  is  deficient,  making  a  most  minute  examination, 
no  point  being  considered  too  trivial  to  be  pieced  in  with  others,  before 


138 


OPERATIONS  ON  THE  ABDOMEN. 


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NEPHRO-LITHOTOMY. 


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I40  OPERATIONS  ON  THE  ABDOMEN. 

it  is  decided  which  kidney  is  the  working  one  and  now  obstructed,  and 
which  is  obsolete. 

Any  operative  interference  should  be  undertaken,  if  possible,  before 
the  stage  of  constant  hiccough  and  vomiting,  twitching  or  convulsions, 
and  drowsiness  deepening  into  coma,  has  been  reached. 

Before  alluding  to  the  operative  steps  to  be  resorted  to  it  will  be  well 
to  remember  that  the  causes  of  suppression  of  urine  which  it  is  thought 
may  be  benefited  by  surgical  interference  are  various  in  their  nature. 

The  first  and  the  one  most  likelj'  to  be  permanently  relieved  is  a 
calculus  impacted  in  the  pelvis  or  the  ureter  of  the  only  working 
kidney.  Another  and  much  less  favourable  class  is  that  where  the  only 
remaining  functional  kidney  is  the  site  of  acute  inflammation  dating  to 
old  calculous  or  tubercular  pyelitis.  Another  class  is  the  traumatic 
one.     Such  cases  are  the  following : 

Mr.  Cock  recorded  (JPatli.  Soc.  Trans.,  vol.  i.  p.  293)  the  case  of  a  youug  man  who 
died  comatose  on  the  eleventh  day  after  an  accident.  All  the  symptoms  of  the  original 
injury  and  the  subsequent  peritonitis  subsided  in  a  few  days,  save  that  the  catheter 
withdrew  nothing  but  blood.  The  autopsy  showed  a  ruptured  single  kidney.  In  Mr, 
Poland's  case  (_Guy's  Hasp.  Reps.,  vol.  xiv.)  the  complete  suppression  of  urine  which 
followed  an  injury  was  due  to  thrombosis  of  the  renal  vessels  of  one  kidney,  and 
rupture  of  the  pelvis  on  the  other  side. 

It  will  be  seen  that  obstruction  by  a  calculus*  is  the  only  one  which 
promises  much  success  to  the  efforts  of  the  surgeon. 

With  regard  to  the  operation  in  cases  of  suppression,  if  the 
patient's  condition  is  good,  and  if  no  sufficient  history  is  forthcoming, 
the  surgeon  will  be  justified  in  examining  the  condition  of  the  kidneys 
by  an  incision  in  the  linea  alba,  being  mindful  of  the  fallacies  to  which 
I  have  alluded  at  p.  135.  If  he  finds  a  stone  in  one  ureter  he  must 
either  push  it  up  to  a  part  where  he  can  cut  down  upon  it  by  the  safer 
lumbar  operation,  or  remove  it  from  the  abdomen  by  the  steps  given 
below,  p.  167.  If  no  stone  is  found,  and  it  is  decided  to  d^-ain  the 
kidney  which  seems  to  be  the  working  one,  this  should  be  done  by  a 
lumbar  incision.  It  is  not  only  safer  for  the  great  majority  of  operators, 
but  it  must  always  be  remembered  that  in  these  cases  of  suppression 
the  working  kidney  is  usually  a  damaged  one,  and  pyelitis  may  be 
present  with  more  or  less  pus  in  the  kidney. 

NEPHRECTOMY.  , 

.   Indications.  I 

i.  Cases  of  renal  tuberculosis,  preferably  as  the  primary  operation  and 
also  cases  of  tuberculous  pyo-nephrosis  explored  previousl}^  and  drained 
by  nepju-otomy,  but  in  which  a  discharging  sinus  persists.  Here  the 
kidney  should  be  removed  when  the  following  conditions  are  favourable 

,  *  In  very  rare  cases  the  ureter  may  be  obstructed  by  a  body,  perhaps  capable  of 
removal,  and  not  a  calculus.  Mr.  Butler,  of  Guildford,  records  (^Lancet,  vol.  i.  1890, 
p.  79),  a  case  of  suppression  of  urine  lasting  thirteen  days.  The  necropsy  showed  that 
the  ureter  of  the  only  working  kidney  (the  left  one)  was  greatly  distended  with  urine 
and  plugged  by  a  solid  hard  body  in  about  its  centre.  This  proved  to  be  a  venous 
thrombus  which,  formed  in  one  of  the  veins  in  the  kidney,  had  passed  through  a  rent 
in  the  kidney  tissue  into  the  pelvis  and  ureter.  Here  the  suppression  came  on  four 
days  after  a  blow  on  the  abdomen.  No  symptoms  had  pointed  to  renal  disease,  and, 
save  that  the  blow  was  on  the  left  side,  there  was  nothing  to  tell  on  which  side  the 
obstruction  was. 


NEPHRECTOMY.  141 

— viz.,  the  age  and  strength  of  the  patient,  the  absence  of  visceral 
infection,  tubeixular  or  lardaceons,  and,  if  possible,  a  date  not  too  long 
deferred,  for  the  additional  reason  that  the  kidney  will  be  increasingly 
matted  down  and  difficult  of  removal,  while  its  fellow  maj'  have  become 
involved  in  the  disease. 

On  this  point  I  may  quote  again  from  my  paper  on  the  conditions 
which  simulate  renal  calculus  (Brit.  Med.  Journ.,  1890,  vol.  i.  p.  117) : 

"  I  would  most  strongly  urge  this  course  (early  exploration  of  the 
kidney)  with  a  twofold  object:  (i)  to  clear  up  the  case,  and  (2)  to 
perform  nephrectomy  if  the  kidney  is  found  to  be  the  site  of  so  fatal  a 
disease.  If  I  am  told  of  the  unwisdom  of  this  step,  owing  to  the  proba- 
bility of  both  kidneys  being  affected,  I  would  reply  that,  as  a  rule,  both 
kidneys  are  not  affected  at  an  early  stage.  Thus  Dr.  Fagge  (Medicine, 
vol.  ii.  p.  488)  gives  a  list  of  thirteen  cases  which  show  'the  characters 
of  tuberculous  disease  of  the  kidney  at  its  commencement.'  In  only 
three  of  these  were  both  kidneys  affected,  and  in  all  these  tubercular 
mischief  was  present  in  the  bladder  also.  If  during  this  early  explora- 
tion one  or  two  pyelitic  dilatations  are  found,  extirpation  of  the  kidney 
should  be  performed  while  the  organ  is  still  small  and  movable,  and 
before  the  rest  of  the  genito-urinary  tract  becomes  involved. 

"  I  need  not  remind  my  hearers  of  the  miseries  which  lie  before  a 
patient  with  established  tubercular  kidney,  the  results  of  ulceration  of 
his  bladder,  with,  perhaps,  vomicae  in  his  prostate,  and  the  inevitable 
course  downhill — arrested,  it  may  be,  for  a  little  while  by  nephrotomy 
and  drainage." 

My  own  experience  of  drainage  alone  in  established  tubercular  kidney 
is  most  unfavourable,  the  relief  being  slight  and  short-lived,  and  not 
arresting  long  the  hectic  and  increasing  debility.  On  the  other  hand, 
in  four  cases  in  which  I  have  been  able  to  perform  nephrectomy  early 
(cases  Nos.  8,  12,  13,  16,  p.  159)  the  result  has  been  most  satisfactory. 
In  four  others  (3,  4,  ii,  17,  ibid.),  the  recovery,  though  less  complete, 
was  very  satisfactory.  Finalh',  in  two  (cases  15  and  22,  ibid.),  the 
eleventh  and  twelfth  cases  in  which  I  have  removed  a  tubercular  kidney, 
the  disease  was  too  advanced  in  both  for  the  result  to  be  satisfactory. 

Ramsa}'  (loc.  cit.,  p.  113)  gives  the  results  of  191  cases  of  primary 
nephrectomy  for  renal  tuberculosis.  Of  these  106  were  noted  as  cured, 
31  were  improved.  37  died  within  one  month  of  the  operation,  and  17 
died  at  a  later  period. 

Forty-nine  cases  of  secondary  nephrectomy  after  a  pi'evious  nephro- 
tomy are  also  given.  Of  these  18  died  shorth' after  the  operation,  and  23, 
or  46  per  cent.,  were  cured.  Of  the  37  deaths  resulting  from  primary 
nephrectomy,  9  were  due  to  uraemia,  3  to  tuberculosis  of  the  other 
kidney,  and  2  to  amyloid  degeneration  of  the  other  kidney.  These  14 
deaths  serve  to  emphasise  the  importance  of  thorough  investigation  of 
the  capacity  of  the  other  kidney  before  nephrectomy  is  decided  upon. 
For  although  the  second  kidney,  as  mentioned  above,  is  not  often 
affected  in  early  cases,  yet  when  the  case  only  comes  under  observation 
in  the  more  advanced  stages,  it  will  very  possibly  be  diseased. 

Should  the  condition  of  the  other  kidney  still  remain  doubtful  after 
the  ordinary  methods  of  investigation  have  been  exhausted,  then  it 
becomes  necessar}'  to  examine  it  by  means  of  an  exploratory  incision. 
Edebohls  {Annals  of  Swgery,  April  1898)  advises  a  lumbar  exploration, 


142  OPERATIONS  OX  THE  ABDOMEN. 

and  this  is  doubtless  the  safer  and  more  certain  method.  The  disturb- 
ance caused  will  be  comparatively  slight,  and  is  more  than  balanced  by 
the  additional  security  that  the  surgeon  will  feel  when  proceeding  to 
perform  nephrectomy  a  week  later.  The  doubtful  utility  of  examination 
of  the  other  kidney  through  an  abdominal  incision  has  been  referred 
to  above  (p.  135).  These  remarks  apply  equally  to  the  two  following 
conditions,  calculous  disease  and  hydro-nephrosis. 

ii.  Calculous  pyelitis  or  pyo-nephrosis  where  the  kidne}'  is  destroyed 
by  long  formation  of  calculi  and  consequent  suppuration,  where 
numerous  calculi  exist  with  sacculation  of  the  kidney,  or  where  a  large 
and  Ijranching  calculus  is  so  embedded  as  to  resist  removal.  These 
indications  for  nephrectomy  have  been  already  considered  under  the 
heading  Xephro-lithotomy  (p.  130),  as  it  is  during  the  performance  of 
this  operation  that  the  question  of  removing  the  kidney  for  the  above 
conditions  will  arise. 

iii.  A  kidney  the  site  of  hydro-nephrosis.  The  tji-eatment  here  will 
vary  according  to  the  degree  to  which  the  disease  has  advanced. 
Aspiration,  lumbar  nephrotonw,  and  drainage,  the  edges  of  the  cyst 
being  stitched  in  the  wound,  and  nephrectomy  have,  each,  been  advo- 
cated here.  Occasionally  repeated  aspirations  are  sufficient,  as  in  Mr. 
Croft's  case  (Clin.  Soc.  Trans.,  vol.  xiv.  p.  107),  in  which  eight  aspirations 
(through  the  lumbar  region)  within  four  months,  between  three  and  four 
pints  being  withdrawn  each  time,  sufficed  to  cure  a  hydro-nephrosis 
in  a  boy  aged  12.  It  is  noteworthy  that  the  case  was  distinctly 
traumatic  in  origin,  and  that  the  last  fluid  withdrawn  contained  a  very 
large  amount  of  albumen.  It  is  for  such  cases,  especially  if  the  interval 
between  the  aspirations  lengthens  each  time,  that  aspiration  should  be 
reserved.  This  method  is,  however,  so  rarely  successful  that  the  surgeon 
will,  in  advanced  cases,  have  to  decide  between  nephrotomy  and 
drainage,  and  nephrectomy.  It  is  now  acknowledged  by  the  advocates 
of  the  former  step  that  it  has  given  less  favourable  results  than  were 
expected.  The  time  taken  is  usually  very  great,  the  frequent  change  of 
dressing  necessitated  by  the  constant  soakage  is  most  irksome,  and, 
later,  the  wearing  of  a  lumbar  urinal  is  most  inconvenient,  leading  as  it 
often  does  to  an  eczematous,  raw  area  around  the  sinus.  The  sinus, 
moreover,  is  liable  to  become  foul  and  to  contain  phosphatic  material. 
The  tube  also,  A\'hich  leads  into  the  urinal  from  the  sinus,  easily  becomes 
blocked,  and  causes  much  discomfort  from  redistension  of  the  cyst. 

In  future,  nephrectomy  will  be  oftener  performed  for  hydro-nephrosis 
where  the  kidney  is  much  altered,  either  as  a  primary  operation  or  after 
allowing  a  sufficient  interval  to  elapse  for  shrinking  of  a  large  cyst,  but 
no  prolonged  delay.  Where,  therefore,  the  patients  are  young,  with 
every  prospect  of  a  long  and  active  life  before  them,  where  a  month's 
drainage  has  failed  to  bring  about  any  considerable  diminution  in  the 
amount  escaping,  and  where  the  fluid  thus  coming  away  contains  but  a 
small  amount  of  urine,  and  where  there  is  evidence  that  the  other  kidney 
is  competent,  the  cyst  and  remaining  kidney  tissue  should  be  extirpated 
from  the  loin  befoi*e  it  has  become  more  firmly  matted  to  the  surround- 
ino-  parts.* 

*  If  in  hydro-nephrosis,  after  an  exploratory  nephrotomy,  bloody  urine  descends  into 
the  bladder,  the  indication  for  leaving  the  kidney  will  be  greater,  especially  if  the 
viscus  show  a  cortex  of  fair  thickness,  and  is  not  a  mere  sac  with  little  if  any  secret- 
ing tissue. 


NEPHRECTOMY 


143 


In  cases  where  the  hydro-nephrosis  is  early  and  due  to  movable  kidnev, 
nephi'orraphy  will  often  suffice  (p.  162).  In  a  few  other  cases  the  lu'dro- 
nephrosis  may  be  due  to  valve  or  stricture  of  the  ureter.  For  an  account 
of  the  different  operations  performed  for  the  relief  of  these  conditions,  I 
may  refer  my  reader  to  the  surgery  of  the  ureter  (p.  167). 

iv.  Certain  cases  of  malignant  disease.  These  fall  into  two  groups, 
which  must  be  looked  at  separately  from  an  operative  point  of  view. 
One  group,  the  sarcomata,  occurs  in  children  before  ten,  usuallv  much 
earlier,  before  five.  In  such  cases  the  risks  of  immediate  death  from 
shock,  aided  often  by  peritonitis,  of  early  recurrence,  or  of  death  from 
secondary  deposits  elsewhere,  should  be  put  clearly  before  the  parents, 
together  with  the  certainty  of  an  early  death  if  the  groT\i:h  is  left. 

The  other  group,  the  ca/rcinomata,  occurs  usually  in  patients  past 
middle  age. 

In  either  case,  an  operation  should  only  be  performed  in  an  early 
stage,  while  the  growth  is  still  internal  to  the  capsule,  and  while  the 
strength,  health,  and  condition  of  the  viscera  are  satisfactory.  On  the 
other  hand,  where  the  history  makes  it  probable  that  the  growth  has 
got  beyond  the  earlier  stage,  when  there  is  any  extension  to  the  lumbar 
glands  or  other  \'iscera.  when  there  is  nausea,  emaciation,  or  a  tempera- 
ture inclined  to  fall,  the  time  for  operation  has  gone  by.  So,  too,  anv 
ascites  or  oedema  of  the  lower  limb  are  absolute  contra-indications. 

With  regard  to  the  frequency  of  secondary  deposits,  the  fact  that  Dr.  Dickinson* 
iound  these  to  be  present  in  no  fewer  than  15  out  of  19  cases  strengthens,  very 
decisively,  the  argument  in  favour  of  early  operations  while  these  growths  are  small, 
at  which  time,  moreover,  they  can  be  successfully  attacked  through  a  lumbar  incision 
sufficiently  enlarged  by  the  steps  given  at  p.  148,  or  by  one  made  anteriorly. 

Much  information  may  be  gained  from  a  very  complete  studv  of 
sarcoma  of  the  kidney  in  children  by  Mr.  George  Walker,  of  Baltimore 
{Annals  of  Surijer;/,  vol.  ii.  1897,  P-  529  et  seq.).  In  all,  74  cases  in 
which  nephrectomy  was  performed  are  here  collected.  Of  these  27 
died  from  the  effects  of  the  operation,  28  died  from  recurrence,  14  passed 
out  of  sight,  and  4  remained  well  from  three  to  five  years  after  the 
operation.  The  immediate  mortality  is  therefore  36"4  per  cent.  Thouo-h 
still  very  high,  this  is  a  vast  improvement  on  the  earlier  published 
figures  ;  for  instance,  Butlin  {Oper.  Surg,  of  Mali</.  Disease,  p.  254) 
gives  60  per  cent.  As  regards  cures,  4  cases,  or  5-4  per  cent.,  mav 
be  considered  as  probable  cures,  but  it  is  quite  possible  that  some  of  the 
14  cases  that  passed  out  of  sight  were  cured,  since  they  were  all  of 
them  well  when  last  heard  of;  in  this  case,  5*4  per  cent,  is  too  low. 
Briefly,  the  most  important  points  in  connection  with  these  four 
successful  cases  are  as  follows  : — 

1.  Israel's  case.  Boy  aged  14  years.  The  tumour,  about  double  the  size  of  a  man's 
fist,  was  removed  through  a  T-shaped  lumbar  incision.  The  peri-renal  fatty  tissue 
was  freely  excised  after  removal  of  the  growth.     "Well  five  years  later. 

2.  Schmidfs  case.  Girl  aged  6  mouths.  The  tumour  was  the  size  of  a  child's  head, 
and  was  removed  through  an  incision  two  fingers'  breadth  to  the  left  of  the  middle  line 
of  the  abdomen.  The  peritonaeum  was  not  sutured.  The  child  was  weU  four  years 
later. 

3.  Ahhv's  case.  Girl  aged  2  years.     The  tumour,  which  weighed  2i  lbs.,  was  removed 

♦  Dis.  of  the  Kidney  and  Uiinary  Derangement*. 


144  OPEEATIONS  ON  THE  ABDOMEN. 

through  a  transverse  incision  extending  from  the  lumbar  region  to  near  the  middle 
line  of  the  abdomen.     The  child  was  well  four  years  after. 

4.  Abbess  case.  Girl  14  months  old.  A  transverse  incision  was  again  used,  ex- 
tending from  the  middle  line  of  the  abdomen  to  within  6  cm.  of  the  spine.  The 
child  weighed  15  lbs.,  the  tumour  7^  lbs.  The  child  was  well  three  and  a  half  years- 
later. 

Mr.  Walker  also  compares  the  length  of  life,  from  the  time  of  the 
discovery  of  the  tumour,  in  cases  not  operated  on  with  those  that  were 
operated  on.  In  68  cases  not  operated  on  the  average  length  of  life 
was  8'o8  months,  in  the  operation  cases  the  average  was  i6'77  months^ 
an  average  gain,  that  is,  of  S'6g  months  by  operation.  Another  success- 
ful case  is  described  by  Malcolm  (Clin.  Soc.  Trans.,  vols,  xxvii.  and 
xxviii.),  the  child  being  in  good  health  two  years  and  four  months  after 
the  operation. 

Since  this  disease,  when  left  to  itself,  is  necessarily  always  fatal,  a  rate 
of  cure  after  operation  of  at  least  5  per  cent,  constitutes  very  strong 
evidence  in  favour  of  operation  wherever  there  is  a  reasonable  hope  that 
the  whole  of  the  disease  can  be  removed. 

With  earlier  diagnosis  and  improved  technique,  it  is  to  be  hoped 
that  a  still  greater  measure  of  success  will  obtain. 

To  secure  this  improvement  the  following  points  deserve  attention. 
An  exploratory  incision  should  be  made  as  soon  as  obstinate  pain  and 
swelling  (perhaps  revealed  by  an  anaesthetic)  call  attention  to  the 
possibility  of  a  growth,  and  before  time  has  elapsed  for  lymphatic 
infection.  Where  the  case  comes  before  the  surgeon  in  a  more  advanced 
stage,  he  should  bear  Mr.  Malcolm's  advice  in  mind.  As  in  the  "  treat- 
ment of  new  growths  elsewhere,  the  more  definite  the  outline  of  the 
tumour,  the  more  mobile  it  is,  the  slower  its  growth,  the  better  the 
state  of  the  patient's  health— in  fact,  the  stronger  the  evidence  that  the 
patient  is  only  locally  affected,  the  more  likely  is  operative  treatment  to 
be  followed  by  prolonged  immunity  from  disease."  Cases  may  be  observed,, 
on  the  other  hand,  in  which  the  tumour  has  no  definite  outline,  being 
fixed  to  and  incorporated  with  the  neighbouring  structures,  so  as  to  be 
absolutely  immobile,  being  also  of  very  rapid  growth  and  accompanied 
by  extreme  emaciation.  Such  cases  are  obviously  unsuitable  for  surgical 
interference.  "  Before  the  operation  every  precaution  should  be  taken 
against  shock.  Thus  the  limbs  should  previously  be  bandaged  in  cotton 
wool,  the  site  of  the  wound  only  exposed,  the  head  kept  low,  injections 
of  brandy  and  strychnine  should  be  ready,  ether  administered,  warmth 
maintained  by  operating  on  a  hot-water  table  when  possible,  and  warm 
irrigating  fluid  used.  Finally,  an  assistant  should  alwaj^s  be  at  hand  to 
perform  saline  infusion,  and  this,  if  used,  should  be  resorted  to  before 
the  close  of  the  operation,  when  the  condition  of  shock  may  be  irre- 
mediable."* 

During  the  operation  itself  the  incision  must  be  sufficiently  free.  The 
lumbar  one,  carried  very  freely  forwardf  (p.  148),  will  give  sufficient  room. 
The  peritonaeum  will  only  be  opened  when  the  growth  is  very  large  or 
adherent.    Where  grave  shock  is  imminent,  hsemorrhage  may  be  con- 

*  Dr.  Abbe  strongly  advises  the  use  of  the  Trendelenberg's  position  as  emptying 
the  blood  from  the  growth  into  more  important  parts,  and  the  injection  of  strong 
cofEee  and  brandy  into  the  rectum  after  the  operation. 

f  Dr.  Abbe  used  a  similar  one  in  his  two  successful  cases  mentioned  above. 


XEPHRECTOMY.  145 

trolled  by  forceps  left  in  situ  for  thirty-six  or  forty-eight  hours. 
It  is  easy  to  prevent  a  child  from  rolling  on  to  these  by  packing  the 
patient  firmly  on  either  side  with  pillows  in  a  cot.  Finall)^,  as  5lr.  Malcolm 
has  shown,  every  vestige  of  the  capsule,  and  all  fat  adjacent  to  it,  together 
with  any  fat  or  glands  about  the  renal  vessels,  should  be  removed. 

v.  Certain  cases  of  injury.  These  are  veiy  rare,  and  fall  into  the 
following  groups  :  (a)  Where  an  injured  kidney  protrudes  from  a 
wound  of  the  abdomen,  usually  the  loin,  (h)  In  some  cases  of  non- 
penetrating wound  of  the  kidney,  as  when  it  is  ruptured  from  a  fall  or 
blow,  (i)  Where  htematuria  does  not  yield  to  treatment,*  the  bleeding 
being  well  marked,  or  latent  and  insidious,  giving  evidence  indirectly  of 
its  existence  by  the  increasing  pallor,  the  failing  pulse,  impending 
syncope,  and  perhaps  a  swelling  in  the  loin,  as  in  case  No.  20,  Table, 
p.  161.  (2)  Later  on,  when  the  injured  kidney  is  setting  up  serious 
suppuration,  which  does  not  yield  to  drainage.  (3)  For  ruptured  ureter 
and  traumatic  hydronephrosis  :  Mr.  Barker  has  recorded  [Lancet,  Jan.  17. 
1885)  a  most  successful  case,  in  which,  after  other  treatment  had  failed, 
he  removed  a  kidney  three  months  after  the  rupture. 

The  child,  aged  35,  had  been  run  over,  but  beyond  some  bruising  and  one  small 
clot  passed  there  was  nothing  to  point  to  injury  of  the  urinary  tract.  Having  left 
the  hospital  in  a  fortnight,  apparently  convalescent,  he  was,  a  few  days  later, 
admitted  with  a  fluctuating  swelling  in  the  right  loin.  This  increasing,  was  aspirated, 
the  fluid  yielding  ^  per  cent,  of  urea.  The  swelling  was  subsequently  drained,  and 
the  drainage-tube  becoming  blocked  with  phosphatic  deposits,  and  thus  causing  a 
good  deal  of  constitutional  disturbance,  the  kidney  was  removed.  It  proved  to  be 
healthy,  the  ureter  being  torn  across  just  below  it. 

(c)  Penetrating  wounds.  Very  rarely  indeed  nephrectomy  may  be 
called  for  here  (i)  when  liEemorrhage  does  not  yield  to  treatment  aided 
by  exploration  and  plugging  ;  (2)  when  a  urinary  fistula  persists  after 
such  a  wound  in  certain  cases — e.g.,  when  the  other  kidney  is  healthy. 
('/)  Gunshot  wounds.  Owing  to  the  increase  of  revolver-injuries  and 
recent  advances  in  abdominal  surgery,  this  matter  has  lately  received 
much  attention.!  Whether  in  civil  or  military  practice,  gunshot  wounds 
of  the  kidney  are  only  too  likely  to  be  complicated  with  injuries  of  the 
intestines,  liver,  and  spine.      When,  in  the  course  of  an   exploratory 

*  In  Mr.  Rawdon's  case  Qoc.  infra  cit.')  nephrectomy  was  performed  for  haemor- 
rhage after  an  injury,  but  at  rather  a  later  date — e.ff.,  on  the  seventeenth  day  after 
the  fall — to  prevent  blood  from  entering  the  bladder  and  increasing  the  acute 
cystitis  present.  Here  the  hjematuria  had  diminished  at  first,  and  subsequently 
increased. 

t  As  might  bo  expected,  American  surgeons  have  not  been  slow  to  avail  them- 
selves of  their  opportunities.  Prof.  Nancrede  QAnnals  of  Surgery,  June  1887,  p.  480) 
suggests  that  where  the  renal  or  splenic  artery  is  cut  by  a  bullet  the  viscus 
should  be  removed,  as  gangrene  is  inevitable.  Dr.  Parkcs  Qoc.  supra  cit..  Nov. 
1887,  p.  379),  in  a  case  of  bullet-wound  of  the  abdomen,  having  sewn  up  five  perfora- 
tions of  the  intestine,  found  that  the  left  kidney  was  perforated.  The  hsemorrbago 
was  very  slight  at  this  time.  After  doing  well  for  twenty-four  hours,  the  patient 
began  suddenly  to  fail,  and  died,  collapsed,  from  haemorrhage  from  the  kidney.  Dr. 
Parkes  regretted  that  he  had  not  performed  nephrectomy.  Dr.  C.  Briddon,  of  New 
York  (^Anrmls  of  Suryerij,  1894,  vol.  i.  p.  641),  in  three  cases  explored  an  injury  to  the 
kidney  by  a  lumbar  incision  at  a  date  varying  from  one  to  four  weeks  after  the 
accident,  and  by  evacuating  bloody  urine,  foetid  clots,  irrigating,  and  tamponnading 
with  iodoform  gauze,  saved  his  patients  from  a  state  of  grave  periL 

VOL.    II.  10 


146  OPEEATIONS  ON  THE  ABDOMEN. 

operation  in  the  case  of  a  gunshot  wound  of  the  abdomen,  the  kidney 
is  found  to  be  the  seat  of  hsemorrliage,  if  uncontrollable  by  other  means, 
nephrectomy  shoiild  be  performed. 

vi.  In  a  very  few  cases  of  movable  kidney.  Where  nephrorraphy 
has  been  properly  performed,  as  e.g.,  by  the  method  given  at  p.  165, 
nephrectomy  will  never  be  required.  In  a  few  cases  nephrorraphy  will 
fail,  owing  to  the  complication  of  organic  disease,  as  in  the  instances 
given  at  p.  163. 

vii.  For  a  few  rare  diseases  of  the  ureter.  Israel's  case  (quoted  at 
p.  1 20)  of  chronic  ureteritis,  for  which  nephrectomy  was  performed,  may 
be  again  referred  to  here.  Another  very  instructive  case,  one  of  ureteral 
papillomata,  is  described  by  Le  Dentu  and  Albarran  [Bull,  de  l}Acad.  de 
Med.,  No.  9,  1899)  : 

Male,  33,  had  had  frequent  attacks  of  renal  colic  for  which  nephrotomy  had  been 
performed  without  benefit.  A  diagnosis  of  ureteral  papilloma  was  arrived  at  by  means 
of  the  cystoscope.  The  kidney  and  ureter  were  therefore  removed.  The  kidney  was 
hydronephrotic,  and  the  ureter  contained  two  papillomata,  one  three-quarters  of  an 
inch  below  the  renal  pelvis,  the  other  at  the  vesical  orifice. 

viii.  Hydatid  disease  of  the  kidnej'.  Jerosch  {Centralhl.  f.  Ghir., 
No.  38,  1899)  has  recently  recorded  two  cases  of  nephrectom}"  for  this 
rare  condition.  In  the  first  case,  death  took  place  on  the  third  day  from 
exhaustion ;  the  second  case  recovered. 

ix.  Aneurysm  of  the  renal  artery.  Prof.  W.  W.  Keen  (Philad. 
Med.  Journ.,  May  5,  1900)  reports  a  successful  case  of  nephrectomy  for 
this  rare  form  of  aneurysm  : 

The  patient  was  a  lady,  aged  45,  who  had  sufEered  for  about  five  years  from  severe 
attacks  which  began  with  chilly  sensations,  followed  by  nausea  and  considerable  rises 
of  temperature.  These  attacks  lasted  a  variable  time  and  were  thought  to  be 
"  bilious."  Once  only,  during  the  last  attack,  there  was  a  small  amount  of  blood 
in  the  urine.  A  large  tumour,  thought  to  be  probably  a  hydronephrosis,  was  found 
occupying  the  whole  right  ilio-costal  space,  and  extending  from  the  right  flank  to 
a  point  about  5  cm.  beyond  the  middle  line.  The  tumour,  which  was  removed 
without  great  difficulty,  was  found  to  consist  of  the  kidney  flattened  out  on  the 
surface   of  a  large  aneurysm  of  a  branch  of  the  right  renal  artery. 

Prof.  Keen  gives  abstracts  of  twelve  similar  cases,  two  of  which  were 
operated  on.  Recovery  took  place  in  both  these.  Prof.  Keen  remarks 
that  "  there  is  nothing  peculiar  al)out  any  of  the  three  operations  other 
than  the  danger  of  liBGmorrhage,  especially  from  the  pedicle.  In  my 
own  case  the  pedicle  was  broader  than  I  have  ever  encountered  in  any 
prior  case  of  nephrectomy,  so  that  I  had  to  tie  it  in  seven  different 
sections.  All  three  of  the  operative  cases  have  terminated  in  recovery, 
a  most  encouraging  outlook  for  the  future." 

Operations. 

These  are  :  A.  Through  the  Lumbar  Region.  B.  Through  the 
Abdominal  Wall,  and  the  Peritonseum  as  well— (a)  by  an  incision 
at  the  outer  eAge  of  the  rectus;  (/>)  by  one  in  the  linea  alba.  C. 
Through  the  Abdominal  Wall,  without  opening  the  Peritonseum. 
These  methods  are  compared  at  p.  156.  D.  A  Combination  of  the 
Abdominal  and  Lumbar  Incisions.  E.  Knowsley  Thornton's  Com- 
bined Method. 


NEPHRECTOMY.  1 47 

A.  Lumbar  Nephrectomy. 

Operation. 

The  position  *  of  the  patient  and  the  earlier  steps  are  much  as  those 
already  given  in  the  account  of  Nephro-lithotomy,  p.  123. 

When  the  lumbar  fascia  has  been  slit  up  and  the  fat  around  the 
kidne}"  torn  through,  this  organ  should  be  ^^'ell  thrust  up  by  an  assistant 
making  careful,  steady  pressure  with  his  fist  against  the  abdominal 
wall ;  the  wound  being  now  widely  dilated  with  retractors,  the  surgeon 
examines  the  kidney,  and  has  next  to  decide  on  three  points : 

(i)  Is  removal  required  ?t  (2)  Will  more  room  be  wanted  ?  If  so,  the 
incision  already  made,  slightly  oblicpie  and  aboiit  half  an  inch  below  the 
twelfth  rib,  should  either  be  converted  into  a  T-shaped  one  by  another 
made  downwards  from  its  centre,  or  at  its  posterior  extremity,  along  the 
outer  edge  of  the  quadratus  lumborum,  or  continued  downwards  and 
forwards,  as  described  under  Nephro-lithotomy  (rw?e  p.  124).  Additional 
room  may  also  be  gained  bj^  an  assistant  slipping  his  fingers  under  the 
lower  ribs  and  drawing  them  forcibly  upwards.  (3)  Is  the  kidney 
firmly  matted  down  or  no  ?  If  there  has  been  no  surrounding  inflam- 
mation, the  extra-peritonfeal  fat,  the  peritonaeum,  and  colon  will  be 
readily  separated  by  the  finger  working  close  to  the  kidne}^  until  the 
pelvis  and  vessels  are  reached.  But  if  inflammation  has  caused  firm 
adhesion  and  matting  down  of  the  kidney  to  adjacent  parts,  the  altered 
fat  and  thickened  and  adherent  capsule  must  be  divided  down  to  the 
kidney  itself,  and  this  gradually  enucleated  (partly  with  the  finger, 
partly  with  a  probe-pointed  bistourj^)  from  out  of  its  capsule,  which  is 
left  behind. 

The  only  guide  in  such  a  case  is  the  tissue  of  the  kidney  itself,  close 
to  which  the  finger  and  knife  must  be  kept. 

A  case  of  Mr.  H.  Marsh's  well  shows  this  difficulty : 

Eemoval  of  the  kidney  could  not  here  be  effected,  owing  to  its  size  and  the  firmness 
with  which  it  was  embedded  in  the  surrounding  condensed  areolar  tissue.  That  part 
of  the  kidney  which  had  been  exposed  was  accordingly  transfixed  with  a  strong  double 
ligature,  and  cut  away.  Complete  suppression  of  urine  followed  the  operation,  and  the 
patient  died  in  about  thirty  hours.  At  the  post-mortem  examination  the  remaining 
part  of  the  right  kidney  and  its  ureter  were  found  to  be  so  firmly  embedded  in  dense 
cicatricial  material  that  they  were  dissected  out  only  with  diflSculty.  The  kidney 
itself  was  converted  into  numerous  sacculi,  in  the  walls  of  which,  however,  some 
remains  of  renal  structure  could  still  be  traced.  The  opposite  kidney  weighed  6  oz. 
Its  capsule  was  adherent,  and  there  were  two  or  three  cysts  on  its  surface.  On 
section,  its  structure  looked  somewhat  confused  and  cloudj'-,  but  its  condition  was  not 
such  as  to  indicate  advanced  disease. 

Mr.  Greig  Smith  stated  {Ahdom.  Surtj.,  p.  508)  that,  in  cases  of  old- 
standing  suppuration  with  great  enlargement,  the  vena  cava  and  the 
aorta  may  be  intimately  adherent  to  the  capsule.  "  One  such  case  was 
met  with  in  the  post-mortem  room  of  the  Bristol  Infirmar}- ;  here  it 
was  simply  impossible,  after  death,  to  dissect  apart  the  venous  wall  and 

*  Additional  care  should  be  taken  to  open  out  the  space  between  the  last  rib  and  the 
crest  of  the  ilium  by  the  arrangement  of  pillows  underneath  the  loin ;  the  precautions 
given  to  avoid  shock  (p.  144)  must  also  be  taken  here. 

t  This  question  has  already  been  alluded  to  in  the  case  of  a  strumous  kidney  incised 
and  drained  (p.  140)  ;  in  that  of  a  kidney  much  damaged  by  one  or  more  calculi,  under 
the  subject  of  Nephro-lithotomy  (p.  130)  ;  and  in  the  case  of  hydroucphrosis  (p.  142). 


148  OPERATIONS  ON  THE  ABDOMEN. 

the  renal  capsule.  In  another  case,  for  similar  reasons,  the  organ  conld 
not  have  been  removed  by  any  proceeding  claiming  to  be  recognised  as 
surgical."* 

If  further  room  is  still  required,  this  may  be  easily  and  effectually 
gained  by  making  use  of  additional  incisions  as  recommended  by  Prof. 
Konig,  of  Gottingen  {Gent.  f.  Ghir.,  1886,  Hft.  35  ;  A7171.  of  Surg.,  Nov. 
1886,  p.  445).  This  surgeon,  having  found  great  difficulty  in  getting 
free  access  to  the  kidney  by  the  ordinary  lumbar  incision,  cuts  through 
the  soft  parts  vertically  downwards  along  the  border  of  the  erector  spinaB 
to  just  above  the  iliac  crest.  He  then  curves  the  incision  towards  the 
navel,  and  ends  at  about  the  outer  border  of  the  rectus,  if  necessary 
going  through  this  muscle  to  the  umbilicus.  It  may  be  often  advisable 
to  make  the  perpendicular  cut  oblique,  running  in  a  flat  curve  into  the 
umbilical  part.  All  the  muscles  are  incised  quite  down  to  the  perito- 
neum. This  method  gives  a  surprisingly  free  entrance,  but  it  can  be 
much  improved  by  introducing  the  hand  through  the  perpendicular  part 
of  the  cut,  separating  the  peritonasum  in  front  and  pushing  it  forwards. 
Prof.  Konig  proposes  to  call  this  the  retro-peritoneal  lumbo-abdominal 
incision.  If  sufficient  space  is  not  thus  affijrded,  or  if,  for  diagnostic  or 
operative  purposes,  it  is  desirable  to  approach  the  tumour  from  the 
abdominal  cavity,  the  peritoneum  can  be  divided  in  the  transverse  cut. 
If  infective  material  is  to  be  removed,  this  peritoneal  opening  must  be 
carefully  looked  after. 

Very  large  kidneys  and  renal  tumours  can  be  got  out  through 
very  free  lumbar  incisions.  I  may  state  here  that  I  twice,  in  1890, 
removed  kidneys  eight  inches  long  through  the  ver}^  limited  ilio-costal 
space  of  little  children  aged  respectively  3  and  3^.  One  was  a  case  of 
sarcoma,  the  other  of  cystic  kidney.  Both  made  excellent  recoveries  ;  but 
as,  in  the  former,  the  renal  vein  was  thrombosed  with  growth,  it  was 
clear  that  a  few  months  would  see  the  end.  In  each  case  the  lumbar 
incision  was  carried  forward  ver}^  freely,  and  the  long  axis  of  the 
tumour  brought  out  in  that  of  the  wound. 

In  both  Abbe's  successful  cases  of  sarcoma  (vide  supra,  p.  143) 
long  transverse  lumbar  incisions  were  found  to  give  ample  room,  in 
the  second  case  the  tumour  weighing  yh  lb.  in  a  child  only  14  months 
old.     Many  other  cases  might  be  quoted. 

The  danger  of  ventral  hernia  is  guarded  against  by  using  deep 
sutures,  by  allowing  only  gentle  movements  at  first  when  the  patient 
gets  up,  and  by  the  use  of  a  support.  By  these  means  the  risk  of 
hernia  may  be  reduced  to  a  minimum. f 

When  the  kidney  has  been  sufficiently  enucleated  either  out  of  its 
capsule,  or,  together  with   this,  out  of   the  peri-renal  fat,  the  vessels 

*  As  will  be  seen  from  Case  22  in  the  table  at  p.  161,  in  which  I  injured  the  vena 
cava  in  the  case  of  a  large  tubercular  kidney,  very  adherent ;  the  most  diificult  case 
1  have  met  with.  In  a  case  of  attempted  nephrectomy  (^Amer,  Journ.  Med.  Sci.,  1882, 
vol.  ii.  p.  116)  the  removal  of  the  organ  was  rendered  impossible,  not  only  by  its 
adhesions  to  the  tissues  around,  but  also,  as  was  proved  post  mortem,  to  the  colon  and 
pancreas  as  well. 

t  It  is  noteworthy  that  Prof.  Bergmann,  of  Berlin,  whose  name  is  well  known  in 
connection  with  the  surgery  of  the  urinary  organs,  advocated  the  lumbar  operation 
for  the  removal  of  malignant  growths  of  the  kidney  (^Aiinals  of  Surgery,  Sept.  1886, 
p.  256). 


NEPHRECTOMY.  1 49 

and  ureter  must  be  dealt  with.  The  latter  should  be  taken  first, 
as  this  step,  especially  if  the  ureter  be  enlarged,  will  facilitate  dealing 
with  the  vessels. 

If  the  ureter  is  dilated,  and  contains  foul  pus  or  tubercular  matter, 
it  should  be  divided  as  low  down  as  possible,  and  the  stump  carefully 
cleaned  out  with  a  sharp  spoon  and  dusted  with  iodoform,  or  fixed 
in  the  wound  with  a  suture,  for  fear  of  its  caiising  infection. 

Tlie  vessels  are  then  tied  in  at  least  two  bundles  with  sufficiently 
stout  carbolised  silk,  or  chromic  gut.  This  is  passed,  with  an 
aneurysm-needle  of  sufficient  length  and  suitable  curve,  through  the 
centre  of  the  bundle,  each  half  of  which  is  tied  separately,  and 
finally  one  of  the  ligatures  is  thrown  round  both  halves  together. 
In  passing  the  ligatures,  they  should  be  pushed  well  in  towards  the 
spine,  so  as  to  leave  ample  room  between  them  and  the  kidney 
to  prevent  all  risk  of  their  slipping.  If  the  kidney  can  be  raised 
out  of  the  wound,  passing  the  ligature  is  much  simplified.  If  this 
is  impossible,  the  surgeon  may  find  help  by  having  the  lower  ribs 
well  pulled  up  by  an  assistant,  while  another  keeps  the  kidney 
well  up  by  pressure  against  the  abdominal  walls,  light  being  also  thrown 
in,  in  case  of  need,  by  a  forehead  mirror  or  electric  lamp.  While  the 
ligatures  are  being  tied  and  the  pedicle  divided,  no  tension  should  be 
put  upon  the  vessels. 

As  soon  as  the  ligatures  are  secured  in  position,  the  pedicle  is  snipped 
through  at  a  safe  distance  from  them  with  blunt-pointed  scissors.  If  the 
pelvis  of  the  kidney  contains  foul  or  tubercular  pus,  and  if  there  is 
room,  a  large  pair  of  .Spencer  Wells's  forceps  should  be  put  on  the  ureter, 
and  the  pedicle  cut  through  between  this  and  the  ligatures,  so  as  to 
prevent  the  escape  of  septic  material.  If  any  heemoiThage  now  takes 
place,  it  is  probably  due  to  some  vessel*  not  being  included,  or  to  an 
artery  having  slipped  through  the  knot  owing  to  the  parts  being 
stretched  at  the  moment  of  ligature.  The  bleeding  point,  to  which 
the  ligatures  will  act  as  guides,  is  now  secured  with  forceps  and 
ligatured.     The  ligatures  are  then  cut  short 

When  a  pedicle  presents  especial  difficulties  from  its  shortness,  thick- 
ness, and  the  way  in  which  it  is  overlapped  b}^  the  kidney,  a  preliminary 
ligature  should  be  applied  and  the  kidney  cut  away  well  in  front  of  it,t 
a  step  which  will  give  access  to  the  vessels  and  ureter  ;  a  double  ligature 
is  then  applied  behind  the  temporary  ligature,  which  is  now  removed. 
Again,  where  the  pedicle  is  very  short,  a  portion  of  kidney  may  be  left  to 

*  The  late  Mr.  Greig  Smith  (loc.  supra  cit.')  gave  the  following  practical  hints  as  to  the 
vessels  :  — The  veins  are  a  good  deal  larger  than  the  arteries  and  overlap  them.  At  the 
hilum  the  veins  branch  quite  as  much  as  the  arteries — i.e.,  four  or  five  times — and  the 
subdivision  extends  farther  towards  the  middle  line.  It  is  very  frequent  for  two  or 
more  trunks  to  represent  the  renal  vein,  and  sometimes  surround  the  artery.  The  want 
of  uniformity  in  the  renal  vessels  is  against  the  possibility  of  ligaturing  the  artery  and 
vein  separately.  In  many  cases  this  will  be  found  impossible  ;  in  none  is  it  necessary. 
Indeed,  the  walls  of  the  veins,  by  acting  as  a  sort  of  padding,  may  add  to  the  safety  of 
ligatures,  preventing  the  thread  from  slipping.  Mr.  Greig  Smith  further  states  that 
the  only  deaths  as  yet  recorded  from  secondary  hiemorrhage  were  in  two  cases  where 
the  vessels  were  separately  tied. 

t  Dr.  Lange  (New  York  Surg.  Soc,  Nov.  22,  1886;  Aimals  of  Surgery,  April  1887) 
has  shown  that  in  a  case  in  which  he  adopted  this  course  no  sloughing  took  place,  as 


I50  OPERATIONS  ON  THE  ABDOMEN. 

ensure  the  ligature  retaining  a  safe  hold.  I  was  obliged  to  adopt  this 
course  in  a  case  of  nephrectomy  for  calculous  pyelitis  in  which  I  had 
removed  twelve  stones  a  year  before  (case  No.  7,  Table,  p.  159).  A  sinus 
persisted,  which  became  abominably  septic.  As  the  stump  of  the  kidney 
was  foetid,  I  inserted  no  sutures,  and  packed  the  wound  with  strips  of 
sal  alembroth  gauze  wrung  out  of  turpentine.  The  patient  made  a  good 
recovery. 

A  modification  of  the  method  of  leaving  a  portion  of  the  kidney 
to  form  the  pedicle  may  be  made  use  of  in  cases  of  kidneys  of  large 
size  which  cannot  be  brought  through  the  wound.  In  such  cases,  the 
vessels  having  been  secured  by  a  temporary  ligature  or  by  Spencer 
Wells's  forceps,  the  kidney  should  be  cut  away  in  separate  portions, 
thus  doing  away  with  the  struggle  required  in  bringing  out  a  large 
kidney  and  the  risks  of  producing  serious  shock  by  pulling  on  the 
vessels.* 

Another  means  of  treating  the  pedicle,  where  this  is  short  and  matted 
doM^n,  is  to  cut  it  through  piece  by  piece,  securing  each  bleeding  point 
with  compression  forceps,  and  tying  them  off  one  by  one.  Or  the  vessels 
may  be  under-run,  as  in  excision  of  the  knee,  but  on  a  larger  scale  and 
more  en  masse. 

By  such  methods  as  the  above  the  risk  of  wounding  the  cava  or  aorta 
is  avoided.  If  the  amount  of  kidney  left  is  small,  it  will  no  doubt 
atrophy  and  give  no  further  trouble,  but,  if  large,  some  sloughing  will 
probably  take  place  ;  in  such  a  case,  iodoform  or  glutei  should  be  dusted 
on  to  the  stump  and  free  drainage  provided. 

Another  difficulty  which  may  be  present  now  is  caused  by  the  kidney 
having  contracted  adhesions  to  the  peritonaeum  and  some  of  its  contents. 

I  have  three  times  opened  the  peritonasum,  when  using  the  lumbar 
incision.  To  one  case,  a  nephro-lithotom^y,  I  have  alluded  at  p.  128; 
the  other  two  were  cases  of  growth  and  tubercular  pyelitis,  for  which  I 
was  removing  the  kidney.  All  three  cases  recovered.  The  opening,  in 
the  two  latter  cases  a  small  one,  was  at  once  covered  by  an  aseptic  sponge, 
and  sutured  with  fine  chromic  gut. 

Where  it  is  certain  that  septic  fluid  from  the  kidney  has  entered  a 
wound  in  the  peritongeum,  the  surgeon  shoiild,  after  the  operation  is 
completed,  make  a  small  opening  in  the  lower  part  of  the  linea  alba, 
wash  out  the  jieritongeal  cavitj'  with  boiled  water,  and  place  a  drainage- 
tube  in  Douglas's  pouch,  this  being  regularly  emptied  as  often  as  is 

the  thick,  fleshy  part  of  the  pedicle  beyond  the  ligatures  was  gradually  absorbed  by 
the  healthy  granulations  of  the  wound,  which  remained  aseptic.  Dr.  Leopold  (^Areh. 
filr  Gyndk.,  xix.  i),  in  a  case  of  nephrectomy,  tied  the  pedicle  in  three,  and  left  a 
triangular  portion  of  the  kidney  parenchyma,  in  order  to  prevent  haemorrhage.  The 
patient  made  a  good  recovery. 

*  The  question  of  how  far  serious  shock  may  be  induced  by  tightening  ligatures  on 
parts  in  such  intimate  relation  with  the  abdominal  sympathetic  centres  is  one  of  great 
importance  and  needs  further  investigation.  According  to  Mr.  Barker  QDict.  of  Surg., 
vol.  ii.  p.  49),  who  has  taken  the  trouble  to  have  the  pulse  watched  carefully  at  this 
stage  of  the  operation,  it  is  not  much  affected  to  the  touch,  but  a  sphygmographic 
tracing  taken  in  one  case  showed  some  irregularity  during  the  necessary  handling  of 
the  kidney,  and  increased  arterial  tension  when  the  pedicle  was  ligatured.  In  my 
own  experience,  any  alterations  in  the  pulse  are  occasional  only,  and  quite  inconstant. 
Dragging  on  the  pedicle  is  much  more  likely  to  produce  shock. 


NEPHRECTOMY.  1 5 1 

requisite.     Mr.  Page,  of  Newcastle,  adopted  this  plan  in  two  cases,  with 
entire  success  (Lancet,  vol.  i.  1893,  p.  999). 

The  question  may  arise  as  to  what  is  to  be  done  if  hjfimorrhage  still 
persists  after  the  kidney  is  got  out  and  its  pedicle  tied.  Ver}-  few  cases 
will  occur  in  Avhich  ligatures  cannot  be  applied  to  each  bleeding  point 
if  the  wound  be  well  opened  up,  carefully  dried,  and  if  light  be  thrown 
down  to  the  bottom.  But  when  bleeding  still  goes  on,  Spencer  Wells's 
forceps  must  be  applied  to  the  bleeding  point  and  left  in  situ  for  two  or 
three  days,  during  which  time  they  will  also  help  to  drain  the  wound.  I 
have  used  this  method  twice  with  good  results.  If  the  forceps  will  not 
hold,  careful  plugging  must  be  resorted  to,  strips  of  iodoform  or  sal 
alembroth  gauze  wrung  out  of  carbolic  acid  lotion  i  in  20,  the  deepest 
attached  to  silk,  and  systematically  packed  into  the  bottom  of  the  wound 
around  a  large  drainage-tube  till  the  wound  is  thorough^  filled;  an 
external  gauze  dressing  is  then  applied,  and  over  this  a  firm  but  elastic 
padding  of  sal  alembroth  wool,  which  is  kept  in  situ  by  firm  bandaging. 
Mr.  Clement  Lucas  (Trans.  Intern.  Med.  Congr.,  vol.  ii.  p.  271)  nearly  lost, 
from  secondaiy  haemorrhage,  a  case  in  which  nephrectomy  had  been  suc- 
cessfully performed  for  suppurating  strumous  pyelitis.  The  bleeding  came 
on  about  the  fifteenth  day,  probablj^  from  the  ligatures,  which  had  been 
left  long,  being  dragged  upon.  The  haemorrhage  again  occurred  on  the 
sixteenth  day,  when  an  attempt  was  made,  after  opening  up  the  wound, 
to  slip  a  ligature  along  the  old  ones,  and  thus  to  re-tie  the  pedicle. 
Haemorrhage  again  occurring  on  the  seventeenth  da}",  and  the  patient 
being  in  a  most  precarious  state,  the  wound  was  tightly  and  forcibl}" 
plugged  with  two  large  sponges  steeped  in  perchloride  of  iron,  and  the 
abdomen  bound  firml}^  round  with  a  flannel  bandage.  Morphia  Avas 
given  subcutaneously.  About  a  week  later  the  removal  of  the  sponges, 
b}'-  cutting  away  the  protruding  part,  was  commenced,  and  this  Avas 
completed  by  the  end  of  another  week.  No  bleeding  recurred  after  the 
plugging,  and  the  patient  made  a  good  recovery. 

When  all  bleeding  is  stopped,  a  large  drainage-tube  should  be  inserted, 
vdtli  one  end  carried  down  to  the  very  bottom  of  the  wound,  and  the 
other  cut  almost  flush  with  the  surface.  The  wound  is  then  partially 
closed  with  salmon  gut  and  carbolised-silk  sutures,  some  iodoform  dusted 
in,  and  aseptic  dressings  applied.  If  there  has  been  much  difficulty  in 
getting  out  the  kidney — and  in  cases  of  old  inflammation  it  has  to  be 
dug  out  by  touch,  with  very  little  help  from  sight — as  in  case  No.  2, 
Table,  p.  159 — no  sutures  should  be  used,  the  wound  being  merely 
lightly  plugged  with  iodoform  gauze  wrung  out  of  carbolic  acid  lotion 
I  in  20. 

Dr.  Weir,  of  New  York  (Ann.  of  Surg.,  April  1885,  p.  311),  during  a  nephrectomy 
in  a  young  woman  the  subject  of  pyonephrosis,  met  with  very  severe  hi^morrhage 
after  ligature  of  the  pedicle.  This  had  apparently  been  effected  with  a  single  ligature. 
After  removing  the  kidney,  a  gush  of  venous  blood  ensued,  which  was  only  partly 
arrested  after  repeated  seizures  with  long  pressure-forceps,  but  was  finally  controlled  by 
stuffing  the  wound  full  of  sponges  and  turning  the  patient  on  her  back.  The  shock 
was  profound,  and  all  the  measures  to  produce  reaction  were  resorted  to.  Transfusion 
performed  twice  to  a  total  amount  of  22  oz.  gave  rise  at  first  to  great  improvement,  but 
the  patient  died  ten  hours  after  the  operation.  The  necropsy  showed  that  the  haemor- 
rhage came  from  a  vein  of  considerable  size,  1-5  centimetre  above  those  secured  by  the 
ligature  and  forceps. 


152  OPEEATIONS  ON  THE  ABDOxMEX. 

B.  Nephrectomy  by  Abdominal  Incision  through  the 
Peritonaeum. 

a.  By  Langenbiich's  Incision  at  the  Outer  Edge  of  the  Rectus. 

h.  By  an  Incision  in  the  Linea  Alba. 

These  two  methods  may  be  taken  together.  The  former  is  the  one 
most  usually  employed,  as  it  has  the  following  great  advantages : — 

I.  The  incision  is  nearer  the  vessels  and  ureter.  2.  There  is  much 
less  general  exposure  of  the  peritoneal  sac  (Knowsley  Thornton). 
3.  The  kidney  is  reached  through  the  outer  or  posterior  layer  of  the 
meso-colon,  a  step  which  avoids  (a)  htemorrhage  and  (h)  the  risk  of 
sloughing  of  the  colon,  as  it  is  the  inner  or  anterior  layer — that  between 
the  colon  and  the  middle  line — which  contains  most  of  the  vessels  to  the 
colon,  and  is  especially  rich  in  veins.  It  is  this  layer  which  is  divided 
in  the  incision  through  the  linea  alba.  4.  The  operation  can  be 
rendered  largely  extra-peritonseal  by  having  the  inner  edge  of  the  cut 
meso-colon  and  that  of  the  parietal  peritonasum  held  in  apposition  or 
sutured  with  catgut. 

Both  operations  give  good  room  for  necessar}'  manipulations,  both 
afford  an  opportunit}'  for  examining  with  the  hand  the  condition  of  the 
opposite  kidne}".*  After  both,  the  wound  can  be  drained  posteriori}' 
from  the  loin,  but  more  easily  after  Langenbiich's  incision. 

a.  Langenbiich's  Incision.  —  The  abdominal  wall  having  been 
cleansed,  an  incision  is  made,  at  least  four  inches  long  at  first,  com- 
mencing just  below  the  ribs,  in  the  line  of  the  linea  semilunaris  on 
the  side  of  the  disease,  the  centre  of  the  incision  being  usuall}^  opposite 
to  the  umbilicus.  The  skin,  subcutaneous  tissue,  and  the  aponeuroses  at 
the  outer  edge  of  the  rectus  having  been  divided  down  to  the  transver- 
salis  fascia,  and  all  ha3morrhaget  having  been  carefully  arrested,  the  trans- 
versalis  fascia  and  the  peritonaeum  are  pinched  up  together,  punctured, 
and  slit  up  on  a  finger  used  as  a  director,  the  hand  is  introduced,  and  the 
size  of  the  growth  and  the  condition  of  the  opposite  kidne}'  investigated. 
In  the  case  of  a  large  growth  the  incision  will  now  be  enlarged,  and 
any  further  lijemorrhage  arrested.  The  growth,  if  large,  is  usually  now 
seen  in  part.  Any  presenting  intestine  is  turned  over  to  the  opposite 
side,  and  kept  out  of  the  way  with  a  pad  of  aseptic  gauze.  The  outer 
or  posterior  layer  of  the  meso-colon  will  now  probably  present  itself, 
pushed  forward  by  the  growth,  which  is  often  bluish-white  in  appearance 
and  covered  by  large  veins.  The  above-mentioned  layer  of  the  meso- 
colon is  next  torn  through,  either  in  a  vertical  or  transverse  direction, 
as  will  best  avoid  the  vessels  exposed.     Any  bleeding  should  be  at  once 

*  I  cannot  but  think  that  this  advantage  of  the  incisions  through  the  peritonaeum 
has  been  made  too  much  of.  In  Mr.  Barker's  words  QDict.  of  Surg.,  vol.  ii.  p.  48), 
"  Though  the  hand  may  reach  the  kidney  opposite  to  the  one  it  is  proposed  to  excise,  its 
soundness  or  the  reverse  cannot  be  ascertained  by  mere  palpation.  Great  enlargement, 
or,  on  the  other  hand,  great  reduction,  in  size,  or  complete  absence,  might  be  detected ; 
but  the  organ  might  be  tubercular,  or  fibroid,  or  contain  a  moderate-sized  calculus, 
and  yet  the  hand  be  unable  to  detect  the  condition."  I  have  also  referred  to  this 
matter,  p.  135. 

f  The  amount  of  this,  as  will  be  familiar  to  all  surgeons  who  have  opened  the 
peritonaeal  sac  by  this  incision  for  intestinal  obstruction,  &c.,  varies  a  good  deal. 
In  the  case  of  growth,  large  vessels  are  often  present  in  the  peritonaeum  over  the 
kidney. 


NEPHRECTOMY.  1 53 

arrested  by  Spencer  Wells's  forceps  and  ligatures  of  fine  silk.  The 
intestines  are  then  packed  away  with  sterile  gauze. 

A  sufficient  opening  having  been  made  in  the  outer  layer  of  the 
nieso-colon,  the  fingers  are  introduced  to  examine  into  and  further 
separate  the  connections  of  the  kidney. 

During  all  the  necessary  manipulations  in  the  case  of  a  growth,  the 
greatest  possible  gentleness  must  be  used  so  as  not  to  rupture  the 
capsule.  In  rapidly  growing  sarcomata,  especially  in  children,  the 
consistency  may  be  jelly-  or  glue-like,  and  thus,  if  the  capsule  is  opened, 
portions  of  the  gro^^i:h  may  readily  be  left  behind.  Again,  hsemor- 
rhage  may  easily  follow  this  accident,  and  prove  most  embarrassing.* 
If  the  bleeding  is  of  the  nature  of  troublesome  oozing  it  may  be  met 
by  packing  the  cavity  with  iodoform  gauze,  the  ends  of  which  are 
brought  out  through  a  counter-incision  in  the  loin.  The  wound  in  the 
peritona?um  is  next  carefully  sutured  over  the  gauze,  thus  shutting  off 
the  abdominal  cavity.  The  gauze  may  be  removed  in  forty-eight  hours 
(F.  Page,  Lancet,  vol.  ii.  1893,  p.  11 88).  If  the  bleeding  is  from  one  or 
two  points  which  cannot  be  tied,  Spencer  Wells's  forceps  may  be  left  in 
situ,  and  removed  in  forty-eight  hours. 

The  same  precautions  as  to  not  damaging  the  capsule  should  be  taken 
in  the  case  of  a  kidney  full  of  fiuid.  Where  there  is  any  risk  of  such 
fluid  or  of  soft  growth  escaping  into  the  peritonteal  sac,  sterile  gauze 
should  be  carefully  packed  around,  or  the  cut  edges  of  the  meso-colon 
and  the  parietal  peritonjBum  united. 

If  the  parts  about  the  pedicle  are  free  from  adhesions,  the  vessels 
may  be  tied  before  the  kidney  is  enucleated,  which  will  render  this 
latter  step  bloodless.  Wherever  it  is  possible,  forcejis  should  be  placed 
on  the  vessels  close  to  the  kidney  before  they  are  divided,  to  save  spilling 
of  blood  from  the  kidne}^ ;  and  where  tliis  contains  pus,  the  same  pre- 
caution should  be  taken  with  the  ureter. 

The  vessels  should  be  tied  \\i\h.  the  precautions  given  above  (p.  149). 
All  dragging  on  the  pedicle  should  be  scrupulously  avoided. 

The  kidney  being  removed,  the  site  of  the  operation  is  most  carefully 
cleansed  and  dried.  If  troublesome  oozing  has  occurred  and  is  at  all 
likely  to  persist,  a  large  drainage-tube  had  best  be  passed  out  through 
the  loin  by  pushing  a  short  j^air  of  dressing-forceps  from  the  site  of  the 
kidney  so  that  it  bulges  in  the  loin,  where  it  is  cut  down  upon,  and 
used  to  seize  the  tube.  Another  way  of  draining  is  by  Keith's  tube 
through  the  abdominal  incision,  sucked  out  regularly.  Both  this  and 
lumbar  drainage  should  be  employed  in  complicated  cases.  It  has  been 
suggested  that  the  divided  edges  of  the  meso-colon  may  be  united  with 
a  few  points  of  catgut  suture,  but  this  precaution  does  not  seem  to  be 
absolutely  needful,  as  the  edges  usually  fall  readily  into  apposition. 

Mr.  Knowsley  Thornton  laj^s  stress  upon  his  method  of  treating  the 
ureter.     This  tube  is  taken  last  in  the  enucleation  of  the  kidney,  '"and, 

*  Thus  it  has  even  happened  to  Prof.  Czerny,  whose  experience  in  nephrectomy  is 

almost  unrivalled,  to  be  driven  to  tic  the  abdominal  aorta.  The  profuse  hsemorrhage 
met  with  in  removing  a  large  growth  of  the  left  kidney  could  only  be  stopped  by 
pressure  on  the  abdominal  aorta.  This  vessel  was  accordingly  tied.  Death  took  place 
ten  hours  later.  It  was  found  that  the  renal  artery  had  been  torn  through  at  its 
entrance  into  the  tumour.  The  ligature  on  the  aorta  had  been  so  placed  that,  while 
the  blood-supply  through  the  left  was  cut  off,  the  right  vessel  was  pervious. 


154  OPEEATIOXS  OX  THE  ABDOMEX. 

before  separation,  its  renal  end  should  be  secured  by  pressure-forceps, 
then  a  ligature  tied  a  little  way  from  the  forceps,  and  a  sponge  placed 
under  it  before  it  is  divided.  Whenever  it  is  possible,  I  enucleate  it  for 
some  distance  from  the  kidney  before  dividing  it,  so  that  its  cut  end, 
"with  the  sponge  under  it,  may  be  at  once  di'awn  outside  the  abdomen ; 
and  afterwards  fix  it  in  the  lower  angle,  or  most  convenient  part  of  the 
abdominal  incision,  with  a  cleansed  safety-pin.  I  regard  this  fixing  out 
of  the  stump  of  the  ureter  as  the  most  important  detail  in  the  operation, 
and  in  every  case  in  which  I  have  been  obliged  to  cut  it  off"  deep  in  the 
wound  I  have  had  distinct  evidence  of  suppuration  and  trouble  around 
it."  Mr.  Thornton  considers  the  objection  that  this  method  risks  the 
occurrence  of  future  intestinal  obstruction  an  entirely  fanciful  one.  At 
the  worst,  a  ureter  so  treated  is  onlv  a  slight  ridge  over  a  small  surface 
of  the  abdominal  wall,  quickly  disappearing  by  atrophy.  Other  surgeons, 
who  have  treated  the  ureter  b_v  ligature  and  dropping  it  in,  have  not 
met  with  the  results  of  suppuration  and  sloughing  which  Mr.  Thornton 
thinks  are  very  likely  to  follow  on  this  course.  The  onl}'  after-trouble 
which  I  have  known  the  ureter  to  give  is  in  cases  of  removal  of  tuber- 
cular kidney.  Unless  this  operation  is  performed  at  a  very  early  stage, 
there  must  always  be  a  great  risk  that,  owing  to  the  ureter  having 
become  involved,  the  mischief  will  spread  to  the  bladder. 

Ramsay  (loc.  siqrra  cit.)  discusses  the  mode  of  dealing  with  the  ureter 
in  tuberculous  cases  at  some  length,  and  quotes  Eegnier  as  having 
removed  a  tuberculous  ureter  some  months  after  the  nephrectomy^ 
Kelly,  in  the  Johns  Hopldns  Bulletin,  March  1896,  reports  three  cases 
in  which  he  removed  the  whole  of  the  tuberculous  ureter  with  success  at 
the  time  of  the  nephrectomy.  On  the  other  hand,  there  is  evidence  to 
show  that  tuberculous  disease  of  the  ureter  tends  to  undergo  a  process 
of  cure  after  nephrectomy.  One  case  in  point  is  that  of  Tilden  Brown 
{Annals  of  Surgert/,  1899,  vol.  i.  p.  755).  Here  the  kidney  was  removed 
and  the  ureter  left  behind.  At  the  necropsy,  some  months  later,  the 
ureter,  previously  as  thick  as  the  thumb,  had  diminished  to  one-fourth 
its  size. 

Ramsay's  conclusions  on  this  point  are  as  follows  :  "  It  is  safest  to 
remove  the  ureter  with  the  kidney,  as  a  persistent  fistula  may  give 
trouble  if  it  is  allowed  to  remain  in  the  body;"  and  again,  "that  a 
certain  proportion  of  these  fistulse  will  finally  disappear,  either  after  the 
removal  of  a  deep  suture,  or  because  of  the  slow  disappearance  of  the 
tubercular  disease  in  the  ureter,  which,  in  these  cases,  gradually  changes 
into  a  fibrous  cord." 

h.  Nephrectoniy  by  an  Incision  in  the  Linea  Alba. — For  reasons 
already  given,  ]).  152,  this  method  is  not  recommended,  that  of  Langen- 
biicli,  alread}^  fully  described,  being  preferable. 

The  incision  in  the  linea  alba  will  not  materially  differ  from  that  for 
ovariotomy  or  abdominal  exploration,  and  the  same  precautions  are 
called  for  in  removing  a  kidney  by  this  method  as  in  that  through  the 
linea  semilunaris,  of  which  the  chief  only  need  be  recapitulated  here — 
viz.: 

I.  Keeping  the  intestines  well  over  to  the  opposite  side  by  carefully 
applied  gauze.  2.  By  the  same  means  keeping  the  general  perito- 
nieal  cavity  shut  off  as  much  as  possible ;  as  pointed  out  already',  this 
method  has  the  grave  objection  of  more  readily  causing  infection  of  the 


NEPHRECTOMY.  1 55 

peritonaeum.  3.  Avoiding  all  large  vessels  which  are  met  with  over  the 
kidney,  and  securing  these  carefully  with  chromic  gut  or  fine  carbolised 
silk  ligatures  before  dividing  them.  4.  Securing  as  full  access  as  pos- 
sible to  the  kidney  pedicle.  5.  Dealing  as  gently  as  possible  with 
the  kidney  when  distended  with  fluid,  and  still  more  when  it  is  the 
seat  of  a  soft  vascular  growth.  6.  Separating  adhesions,  especially  any 
situated  posteriorly,  with  the  utmost  carefulness.  7.  Avoiding  all  ten- 
sion on  the  pedicle.  8.  Scrupulously  cleansing  the  site  of  the  wound. 
9.  If  fluids  or  portions  of  the  growth  have  escaped  into  the  general 
peritonEeal  sac,  ensuring  cleansing  of  this  with  sponges,  or,  perhaps 
better,  b}*  irrigation  with  a  warm  solution  of  normal  saline.  10.  Taking 
care  that  the  cut  edges  of  the  peritonaeum  over  the  kidney  are  in  exact 
apposition,  either  by  natural  adaptation  or  by  the  aid  of  catgut  sutures. 
II.  Providing  suflicient  drainage  (p.  153)  if  the  operation  has  been  a 
difficult  one  and  the  parts  much  disturbed,  and  especialh'  if  septic  fluids 
have  escajDed  into  the  periton^eal  cavity.  In  this  latter  case  irrigation 
with  boiled  water  or  a  2  per  cent,  solution  of  hot  boracic  acid  must  be 
made  use  of.  12.  Conducting  the  difi*erent  steps  of  the  operation, 
especially  the  earlier  ones,  with  as  much  expedition  as  possible,  and,  in 
addition,  providing  against  shock  by  taking' those  precautions  recom- 
mended for  this  purpose  in  any  grave  operation,  as  at  p.  144. 

C.  Nephrectomy  through  the  Abdominal  Wall,  but 
without  opening  the  Peritonaeum. — Having  made  use  of  the 
method  in  one  case  nine  years  ago,  and  being  much  struck  by  the  room 
afforded,  I  may  make  brief  mention  of  it : 

The  patient  was  a  woman,  aged  54,  the  subject  of  a  movable  kidney  on  the  right 
side,  the  kidncv  being  also  the  seat  of  malignant  disease.  As  the  abdominal  walls 
were  thin,  and  as  the  kidney  could  easily  be  made  to  project  in  the  anterior  part  of 
the  right  lumbar  region,  I  made  a  longitudinal  incision  from  the  anterior  superior 
spine  up  to  the  eighth  rib.  The  different  layers  were  cut  through,  very  little  hiemor- 
rhage  being  met  with ;  when  the  peritonaeum  was  reached,  this  was  then  stripped  up 
out  of  the  iliac  fossa,  upwards  and  inwards,  then  upwards  off  the  anterior  surface  of 
the  kidney  until  its  vessels  came  in  view.  Xo  difficulty  was  experienced  in  dealing 
with  the  pedicle — first  the  ureter,  and  then  the  vessels.  The  vena  cava  was  seen  for 
about  i^  inch  receiving  pulsation  from  the  aorta.  The  patient  never  rallied  thoroughly 
from  the  operation,*  and  sank  about  twenty-four  hours  after.  The  necropsy  showed 
ligatures  tirmly  tied;  one  of  those  on  the  renal  vein  had  slightly  puckered  in  the  inner 
surface  of  the  vena  cava.  A  clot  the  size  of  the  little  finger  constituted  aU  the  bleeding 
that  had  taken  place.  The  kidney  was,  save  for  one  small  patch  at  the  lower  part, 
entirely  converted  into  encephaloid  carcinoma.  Two  or  three  of  the  aortic  glands 
were  enlarged ;  there  were  no  other  secondary  deposits. 

D.  Combination  of  Lumbar  and  Abdominal  Nephrec- 
tomy.— Dr.  Hume,  of  Newcastle,  made  use  of  this  method  in  a  case  of 
sarcoma  (Lancet,  vol.  i.  1893,  p.  196)  ; 

An  incision  about  six  inches  long  was  first  made  in  the  linea  semilunaris,  and  the 
swelling  found  to  be  in  the  left  kidney.  A  lumbar  incision  was  then  made  from  the 
middle  of  the  first  cut,  dividing  aU  the  structures  forming  the  abdominal  waU, 
including  the  peritonaeum.  The  intestines  were  pushed  to  the  right  aud  protected 
with  sponges.  The  peritonaeum  covering  the  kidney  was  then  separated  until  the 
whole  growth  was  exposed.     The  large  cavity  left  was  plugged  with  sublimate  gauze 

*  I  think  that  the  thinness  of  the  abdominal  walls  prolonged  the  operation,  owing 
to  my  anxiety  not  to  wound  the  peritonaeum.  As  has  been  said  above,  the  haemorrhage 
was  very  slight,  and  I  was  careful  not  to  pull  upon  the  pedicle. 


156  OPERATIONS  ON  THE  ABDOMEN. 

dusted  with  iodoform,  the  ends  of  the  strips  being  brought  oiit  through  an  opening 
in  the  most  dependent  part  of  the  loin.  The  strips  were  removed  in  thirty-six  hours. 
The  patient  recovered. 

E.  Mr.  Knowsley  Thornton's  Combined  Method. — TJiis  is 
given  at  p.  134. 

a.  Choice    between    Lumbar    and    Abdominal    Nephrectomy. — 

While  it  is  certain  that  all  kidneys  of  small  or  moderately  large 
size  can  be  easily  removed  by  a  lumbar  incision  sufficiently  enlarged 
(p.  147),  time  alone  will  show  whether  I  am  right  in  my  opinion  that 
before  the  lumbar  method  is  abandoned  a  trial  should  be  made  of  such 
a  free  incision  as  Konig's  (p.  148)  when  large  kidneys  have  to  be 
attacked.  And  this  leads  to  the  question  of  chief  importance:  How  far 
is  the  danger  really  increased  by  going  through  the  })eritonfeum  to  get 
at  the  kidne}'  ?  I  am  strongly  of  opinion  that,  in  spite  of  all  the  recent 
improvements  in  abdominal  surger}^  and  their  success  in  preventing 
peritonitis,  interference  with  and  handling  the  contents  of  the  perito- 
neum, save  in  the  shortest  and  simplest  instances,  remains,  on  the  score 
of  sJiocJi,  as  grave  a  thing  as  ever  it  was.  I  am  quite  aware  that,  in  the 
hands  of  a  few  operators,  such  as  the  late  Sir  S.  Wells,  Mr.  K.  Thornton, 
and  Mr.  ]\Ialcolm,  removal  of  kidneys,  even  in  difficult  cases,  through  an 
abdominal  wound  involving  the  peritona3um,  has  given  excellent  results 
— results  perhaps  as  good  as,  or  better  than,  those  by  the  lumbar  method. 
But,  while  allowing  this,  it  cannot,  I  think,  be  lost  sight  of  that  the 
kidney  is  an  extra-peritonteal  organ,  not  one,  like  the  uterus  and  ovary, 
within  the  peritona?al  sac.  It  will  assuredly  never  come  about  that 
removal  of  the  kidney  will  pass,  like  oophoi'ectomy  and  removal  of  the 
uterus  or  its  appendages,  into  the  hands  of  a  few  operators,  however 
specially  skilled  in  abdominal  surgery.  This  being  so,  and  the  organ 
in  question  being  one  behind  and  outside  the  peritonaeum,  while  each 
man  will  decide  for  himself  and  according  to  his  special  experience  and 
line  of  work,  the  majority  of  surgeons  will,  I  think,  prefer  to  make 
their  attacks  from  behind  whenever  this  is  possible.  This  question  is 
also  dealt  with  above  (p.  134). 

Lumbar  Nephrectomy — Advantages: — i.  The  peritonogum,  save  in 
cases  of  exceptional  difficulty,  is  not  opened  or  contaminated.  2.  Efficient 
drainage  is  easily  provided.  3.  The  structures  interfered  with  are  much 
less  important.  4.  As  pointed  out  by  the  late  Mr.  C4reig  Smith,  "  in  the 
case  of  its  being  unwise,  as  in  abscess,  or  in  tumour  affecting  the  sur- 
rounding tissues,  to  proceed  to  removal,  it  is  less  serious  to  the  patient." 
5.  If  the  kidney  is  firmly  matted  down,  as  in  the  cases  given  at  p.  147, 
such  dense  posterior  adhesions  are  most  readily  dealt  with  by  the  lum- 
bar method.  6.  The  lumbar  incision,  if  converted  into  a  T-shaped  one, 
or  prolonged  forwards  by  Konig's  method,  will  give  sufficient  room  for 
meeting  most  of  the  conditions  which  call  for  nephrectomy.  Thus 
modified,  it  will  suffice  for  new  growths. 

Lumbar  Nephrectomy — Disadvantages: — i.  It  is  thought  by  some 
that  too  little  room  is  given  by  this  method  for  the  removal  of  large 
kidneys.  It  has  already  been  shown  (p.  148)  how  extensively  this  inci- 
sion can  be  enlarged.  It  is  doubtful,  therefore,  if  this  objection  holds 
good  for  an}-  cases,  even  those  of  unusually-  long-chested  patients,  or 
those  with  spinal  deformity.  2.  In  a  fat  subject  the  organ  may  be 
difficult  to  reach,  even  when  well  pushed  up  from  the  front,  owing  to 


NEPHRECTOMY. 


157 


the  great  depth  of  the  wound.  3.  The  pedicle  is  less  easily  reached,* 
and  thus,  in  cases  of  difficultj^,  bleeding  at  a  very  important  stage  of  the 
operation  is  less  easily  dealt  with.  4.  If  the  kidney  be  very  adherent, 
important  structures — e.;/.,  the  peritona?um  and  colon — may  be  opened, 
unless  great  care  is  taken.  5.  The  condition  of  the  opposite  kidney 
cannot  be  examined  into.  Possible  fallacies  here  have  been  pointed 
out.  pp.  135,  152. 

Nephrectomy  by  Abdominal  Incisions  in  the  Linea  Alba,  or  at 
THE  Edge  of  the  Kectus,  the  Peritoneal  Cavity  being  opened — 
Advantages: — i.  Additional  room  in  case  of  large  kidneys.  2.  More 
eas}'  access  to  the  pedicle.  3.  The  possibility  of  examining  the  condi- 
tion of  the  other  kidney.  It  has  already  been  pointed  out  (pp.  135,  152) 
that  this  advantage  is  probably  overrated. 

Nephrectomy  by  Abdominal  Incisions  through  the  Peritoneum 
— DiSADVANTA(iES : — I.  The  peritoneeal  sac  is  opened.  2.  The  same 
sac  may  be  seriously  contaminated  if  a  kidnej'  containing  septic 
matter,  or  one  largely  converted  into  soft  growth,  is  ruptured  during 
the  needful  manipulations.  '  3.  The  intestines  may  be  difficult  to  deal 
with,  and  ma}-,  b}^  crowding  into  the  field  of  operation  and  the 
incision  in  the  abdominal  wall,  prove  most  embarrassing.  4.  The 
handling  and  interference  with  the  contents  of  the  peritoneum  may 
cause  considerable  shock.  5.  The  vitality  of  the  colon  may,  b}^ 
interference  Avith  its  blood-supply,  be  endangered,  6.  It  is  more 
difficult,  by  this  method,  to  deal  with  any  dense  adhesions  which 
may  exist  behind  the  kidney.  7.  If  bleeding  follow  the  operation, 
reopening  an  abdominal  wound,  finding  the  bleeding  points  and 
securing  them,  or  plugging  the  wound,  will  be  attended  by  more 
shock  than  the  adoption  of  the  same  course  by  the  lumbar  method. 
A  case  supporting  this  view  is  candidly  reported  by  Mr.  Page,  of 
Newcastle  {Lancet,  vol.  ii.  1893,  P-  i^S/)-  8.  Efficient  drainage  is 
less  easily  provided  in  cases  of  any  contamination  of  the  peritonasal 
cavity,  or  of  oozing  after  the  kidney  is  removed.  9.  The  after- 
complication  of  a  ventral  hernia  is  much  more  probable  by  this 
method,  though  it  must  be  allowed  that  the  free  lumbar  incision 
already  alluded  to  may  he  followed  by  the  same  result. 

Causes  of  Death  after  Nephrectomy. —  i.  Shock. — This  may  be 
induced  by  hemorrhage,  much  traction  on  the  pedicle,  and  thus, 
probably,  interference  with  the  solar  plexus,  injuiy  to  the  colon, 
and,  where  the  peritonasal  sac  is  opened,  by  much  disturbance  of 
its  contents.  2.  Hajmorrhage. — This  is  especially  to  be  dreaded  where 
the  pedicle  is  deep  and  difficult  to  command ;  where  there  are  aber- 
rant renal  vessels ;  where  these  vessels  are  enlarged  and  perhaps 
softened ;  where,  owing  to  too  much  tension  on  the  pedicle,  a  vessel 
retracts  from  within  its  loop  of  ligature  ;  where  the  kidney  capsule 
and  tissue  are  broken  into.  In  the  intra-peritona3al  method  there  is 
the  additional  danger  of  enlarged  veins  within  the  meso-colon.  Second- 
ary hasmorrhage  has  been  alluded  to  above,  pp.  131,  151.  3.  Uremia 
and  Anuria. — These  are  onh"  likely  to  occur  when  it  has  been  impossible 
to  form  a  correct  estimate  of  the  condition  of  the  opposite  kidney,  or 
where,  to  give  a  patient  a  chance,  the  surgeon  operates  in  what  he  knows 

*  This  objection  and  the  next  can  be  met  by  a  very  free  incision  (p.  14S). 


158  OPERATIONS  OX  THE  ABDOMEX. 

to  be  a  doubtful  case.  "Where  there  is  reason  to  believe  that  the  sup- 
pression of  urine  may  be  clue  to  a  calculus  in  the  opposite  kidney,  this 
should  at  once  be  cut  down  upon  in  the  hope  of  finding  a  calculus 
that  can  be  removed.  Mr.  Lucas's  brilliant  example  of  what  nephro- 
lithotomy may  do,  when  such  peril  sets  in  at  a  later  date,  has  been 
referred  to  at  p.  137.  4.  Peritonitis. — This,  if  septic,  is  due  either 
to  mischief  introduced  at  the  operation  or  from  the  kidney.  While  it 
is  certainly  more  likely  to  follow  the  intra-peritona^al  operation,  it  may 
occur  after  that  through  the  loin,  especially  M-hen  much  difficulty  is 
met  with  here,  owing  to  numerous  adhesions,  or  to  Avorking  in  a 
wound  of  insufficient  size.*  5.  Septic  trouble — Cellulitis — Erysipelas 
— Pvtemia. — These  are  especially  likely  when  the  kidney  contains 
septic  matter,  when  the  soft  parts  are  much  bruised,  or  when  many 
fingers  enter  the  wound.  Other,  rarer,  causes  of  death  are—  6.  Pul- 
monary Embolism.  7.  Empyema. — This  may  be  brought  abovit  by 
an  extension  of  septic  cellulitis,  or  by  removing,  during  the  operation, 
a  portion  of  rib  in  order  to  get  more  rQom — a  step  the  danger  of 
which  cannot  be  too  strongly  enforced  Cp.  123).  An  anatomical  pre- 
disposition favouring  the  passage  of  inflammation  from  the  kidney  to 
the  pleura  has  been  pointed  out  by  Dr.  Lange,  of  Xew  York.  This 
authority  on  renal  surgery  found,  in  one  subject,  an  enormous  gap 
in  the  diaphragm,  the  muscle  fibres  being  absent  from  the  ligamentum 
arcuatiim  internum  as  far  as  the  outermost  part  of  the  eleventh  rib. 
Between  these  two  points  the  fibres  of  the  diaphragm  communicated 
in  a  high  arch,  bounding  an  area  in  which  the  fatt}'  tissue  about 
the  kidney  was  in  direct  contact  with  the  pleura.  8.  Intestinal 
Obstruction. — This  occurred  fatally  in  one  of  Mr.  Thornton's  cases. 
He  thought  it  was  brought  about  by  his  suturing  the  two  edges  of 
the  peritonaeum  over  the  kidney  together,  and  thus  producing  kinking 
of  the  large  intestine. 

Partial  Nephrectomy. — This  has  been  rendered  justifiable  by  the 
results  of  experiments  on  animals.  Morris  (loc.  siqrra  cit.)  says, 
'•Tuffier's  experiments  on  animals,  in  1888,  and  Earth's  histological 
researches  supply  ample  proofs  of  the  healing  power  of  the  kidney, 
and  the  process  by  which  healing  is  accomplished,  even  after  extirpa- 
tion of  considerable  portions.  Paoli,  of  Perugia,  performed  extra-peri- 
tonseal  operations  for  resection  of  the  kidney  upon  twenty-five  dogs, 
cats,  and  rabbits,  with  perfect  recovery." 

Morris  also  gives  a  resume  of  eleven  operations,  three  for  cysts, 
three  for  calculous  pyonephritis,  two  for  new  growths,  and  one  each 
for  puerperal  pyonephritis,  renal  fistula,  and  a  patch  of  interstitial 
nephritis  mistaken  for  malignant  disease. 

None  of  these  cases  died ;  nine  made  good  recoveries,  one  required 
nephrectomy,  and  in  one  fistula  resulted. 

Ramsay  (loc.  supra  cit.)  mentions  nine  cases  of  partial  nephrectomy 
for  tuberculous  disease;  in  only  two  of  these,  however,  was  the  result 

*  During  a  uephrectomy  for  pyonephrosis  the  peritonaeum  vras  injured  owing  to 
the  adhesions  of  the  renal  capsule.  As  it  was  thought  certain  that  some  septic  fluid 
had  escaped  into  the  peritonseal  cavity,  this  was  opened  by  a  small  incision  above  the 
pubes  after  the  lumbar  wound  had  been  closed.  Some  ounces  of  bloody  fluid  escaped, 
the  cavity  was  washed  out,  and  a  drainage-tube  placed  in  Douglas's  pouch.  The 
patient  recovered.     (F.  Page,  Lancet,  vol.  i,  1893,  p.  999.) 


NEPHRECTOMY. 


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VOL.    II. 


I  I 


1 62  OPERATIONS  OX  THE  ABDOMEN. 

satisfactory-  One,  reported  by  Israel,  was  well  one  year  later;  the  other, 
by  Morris,  was  well  two  years  later. 

This  operation  may  also  be  performed  in  cases  of  laceration  of  the 
kidney  by  injury,  where  the  greater  part  of  the  organ  is  uninjured. 
Here  the  organ  will  very  likely  be  healtlw,  and  removal  of  an  almost 
detached  part  ma}^  be  sufficient  to  arrest  the  haemorrhage.  Mr.  Keetley 
has  recorded  a  case  of  this  kind  (Lancet,  vol.  i.  1890,  p.  134)  : 

A  young  man  bad  been  crusbed  by  a  waggon-wbeel.  Tbere  was  laceration.  Five 
or  six  bours  after  tbe  accident  he  showed  signs  of  serious  recurrent  bEemorrhage. 
Through  an  incision  a  mass  of  blood-clot  was  scooped  out,  also  tbe  separated  lower 
end  of  the  kidney,  a  deep  bleeding  point  being  compressed  with  sponges,  which  were 
removed  in  twelve  hours.  Convalescence  was  rapid.  No  urinary  fistula  or  bydro- 
nepbrosis  resulted. 

It  may  be  said,  therefore,  that  where,  on  examination  of  the  kidney, 
a  suitable  opportunitj"  presents  itself,  partial  nephrectomy  may  be 
performed,  and  the  greater  part  of  the  kidney  in  this  way  saved. 
The  w^ound  in  the  kidney  may  be  sutured  or  the  heemorrhage  may  be 
arrested  by  means  of  plugging  with  iodoform  gauze,  suturing  being 
the  preferable  method  where  possible;  for  in  this  way  both  hsemorrhage 
and  escape  of  urine  will  be  prevented,  and  rapid  healing  of  the  whole 
wound  thus  secured. 

In  view  of  the  imsatisfactory  results  that  have  attended  this  method 
of  treating  tuberculous  disease,  and  of  the  great  difficulty  there  must 
be  in  making  certain  that  all  disease  has  been  removed,  it  would  seem 
wiser  to  remove  the  entire  kidney  in  such  cases. 

Results  of  Nephrectomy. 

The  foregoing  list  shows  twenty-three  cases  with  four*  deaths.  Tuber- 
cular cases,  where  the  mischief  is  advanced  and  the  adhesions  extensive, 
as  in  case  22 ;  malignant  growths ;  and  cases  of  calculous  pyelitis 
where  both  kidneys  are  affected,  though  one  onl}^  at  the  time  of 
operation  may  contain  stones,  will  alwaj's  keep  up  the  mortality  of 
nephrectomy. 

Mr.  H.  Morris  (iSurgery  of  the  Kidney  and  Ureter,  vol.  ii.  p.  275)  gives 
the  following  statistics  of  his  cases  :  («)  In  twenty-nine  nephrectomies 
for  calculous  disease,  there  were  five  deaths ;  [h)  in  twenty-four  nephrec- 
tomies for  hydro-  and  pyonephrosis  there  were  three  deaths ;  (c)  in 
twenty-two  nephrectomies  for  tuberculosis  there  were  five  deaths ;  (d)  in 
seventeen  nephrectomies  for  tumour  there  were  four  deaths  ;  (e)  in  three 
nephrectomies  for  fistula  there  were  no  deaths.  Thus,  there  were 
seventeen  deaths  out  of  ninety-five  cases. 

NEPHRORRAPHY. 

It  is  well  known  that  nephrorraphy  has  not  always  been  followed  by 
the  relief  expected.  This,  I  think,  is  due  to  one  or  more  of  the  following 
causes : 

I.  The  operation  has  been  performed  in  unsuitable  cases.  (A.)  Cases 
■  where  the  mobility  of  the  kidney  is  only,  in  reality,  a  small  part  of  the 

*  I  have  included  No.  20.  as  I  performed  the  nephrectomy.  Tbe  case  was,  however, 
i  admitted  under  tbe  care  of  another  surgeon,  and  I  was  only  called  to  it  at  tbe  very 
end.  On  the  other  band,  case  15  ought,  perhaps,  to  be  accounted  a  fatal  case  of 
nephrectomy. 


NEPHRORRAPHY.  1 63 

trouble.  Well-marked  instances  of  this  group  avouIcI  be  those  cases 
where  mobility  of  the  kidney  co-exists  with  a  markedly  neurotic  ten- 
dency, a  group  in  which,  were  it  not  for  the  above  tendency,  the  mobility 
of  the  kidney  would  be  little  complained  of;  a  gi'oup  in  which  operation 
has  been  resorted  to  far  too  often,  thus  bringing  much  discredit  upon  it ; 
a  group,  finally,  in  which  nephrorraphy  is  rarely  to  be  resorted  to,  and 
then  only  with  the  greatest  caution.*  In  dyspeptic,  neurotic  women 
approaching  the  menopause  the  operation  should  be  avoided  altogether. 
In  the  neurotic  tendenc}^  lies  one  of  the  chief  difficulties  with  regard 
to  making  a  decision  on  the  question  of  operation.  The  frequency  with 
which  a  highly  nervous  temperament  is  present  suggests  the  obvious 
question.  Would  these  symptoms  have  arisen  were  it  not  for  the  neurotic 
tendency  ?  Any  honest  medical  man  would  answer  that  in  the  majority 
they  would  not.  In  a  certain  nvimber  the  mobility  of  the  kidney  deter- 
mines the  region  and  distribution  of  the  neurotic  trouble;  in  a  very  few 
it  originates  and  causes  the  neurotic  tendenc3\t  Again,  where  the 
mobility  of  the  kidney  is  associated  with  a  general  proptosis  of  the 
viscera,  especially  of  the  liver,  with  long-standing  dyspepsia  or  constipa- 
tion, or  with  uterine  or  ovarian  trouble,  it  will  be  useless  to  perform 
nephrorraphy,  unless  the  other  ailments  can  be  corrected^ — a  matter  of 
no  little  doubt  and  difficulty  in  some  of  those  patients  in  whom  we 
meet  with  this  disorder.  (B.)  In  a  certain  proportion  of  movable 
kidneys — and  this,  perhaps,  a  larger  one  than  is  usuall}^  allowed — 
organic  disease  coexists  as  well.  I  have  met  with  three  such  cases. 
In  one  (Case  i.  Table,  p.  159)  the  kidney  was  the  site  of  carcinoma; 
in  a  second  (Case  8,  loc.  siipra  cit.),  earl}^  tubercular  disease  must 
have,  been  present.  About  two  months  after  the  nephrorraphy,  pain 
having  returned,  further  examination  showed  that  the  urine,  which 
had  before  been  found  normal,  contained  pus.  At  a  second  operation 
two  early  foci  of  tubercular  suppuration  ^  were  found  and  the  kidney 
was  removed.  Six  years  later  the  patient  was  alive  and  well.  The 
third  case  was  one  associated  with  hydronephrosis.  At  this  time, 
when  performing  nephrorraphy,  I  was  passing  my  sutures  through 
the  tissue  of  the  kidney  itself,  a  method  which  I  now  consider 
quite  unreliable,  and  I  am  doubtful  if  the  relief  given  in  this  case 
of  hydronephrosis  was  permanent.  The  question  of  nephrorraphy  in 
hydronephrosis  is  referred  to  below. 

2.  Another  frequent  cause  of  nephrorraphy  failing  to  give  perma- 
nent relief  is  the  way  in  which  the  operation  is  performed.  Too  often 
the  peri-renal  fatty  tissue  has  been  thoroughly  pulled   out,  some  of  it 

*  In  an  interesting  paper  by  Dr.  Drummond  (loc.  infra  cU.'),  thirty  cases  of  movable 
kidney  are  given,  two  of  which  were  treated  by  nephrorraphy.  Both  relapsed.  In  a 
third  case,  the  details  of  which  were  supplied  to  Dr.  Drummond,  "  excision  of  the 
movable  kidney  was  practised  without  any  relief." 

f  As  in  the  rare  cases  where  a  man,  previously  active  and  healthy,  has  his  life  spoilt 
and  becomes  hypochondriacal  after  one  kidney  has  become  movable. 

X  My  silk  sutures,  with  which  the  kidney  had  been  fixed,  were  found  f/i  silii,  but  as 
the  collections  of  pus  were  on  the  inner  aspect  of  the  kidney,  I  do  not  think  they 
dated  to  the  stitching,  in  which  the  kidney  substance  had  been  boldly  taken  up.  The 
early  appearance  of  pus  after  the  nephrorraphy  is,  however,  suspicious,  and  it  is  quite 
possible  that  in  delicate  patients  the  injury  inflicted  by  suturing  might  be  the 
starting-point  of  tubercular  disease  of  the  kidney. 


1 64  OPERATIONS  ON  THE  ABDOMEN. 

removed,  and  its  edges  sutured  to  the  lips  of  the  wound.  Frequently 
the  kidney  is  already  movable  Avithin  this  capsule,  and  no  good  results, 
and  where  no  such  mobility  has  existed,  the  loose  fatty  tissue,  how- 
ever carefully  pulled  out,  tightened  and  stitched,  gradually  stretches 
and  ceases  to  fix  the  organ.  In  other  cases  the  operator  tries  to 
pass  his  sutures  so  as  to  take  up  the  capsule  of  the  kidney  without 
regarding  more  than  the  surface  of  the  cortex.  Such  a  hold  is 
insufficient.  In  other  cases — and  this  is  very  frequent — the  kidney 
tissue  itself  is  deeply  traversed  by  the  needle.  Now,  the  friability  of 
the  kidney  is  well  known.  Eveiy  operator  who  has  passed  sutures 
in  this  way  is  familiar  Avith  their  tendency  to  cut  through  before  or 
just  as  they  are  finally  tightened  and  tied.  So  soft  is  the  tissue  of 
the  kidney,  especially  when  injured  and  inflamed — as  around  a  suture 
— that  I  believe  that,  even  when  silk  sutures  thus  passed  have  been 
left  in  situ,  their  cutting  through  is  only  a  matter  of  time.  When 
catgut,  however  stout,  has  been  employed  the  result  is  still  worse. 
Like  silk,  it  is  ver}'  liable  to  cut  its  way  through  the  easily  lacerable 
kidney  tissue  as  it  is  tied ;  if  it  does  not  do  so  then  its  softening- 
takes  place  so  quickl}'  in  the  vascular  kidney  tissue  that  any  permanent 
anchoring  by  the  blending  of  this  material  with  other  tissues  is  impos- 
sible.* Moreover,  there  is  another  danger,  not  altogether  a  fanciful 
one,  which  ma}^  follow  on  deeply  puncturing  the  kidney.  A  German 
surgeon,  Barth,  has  seen  a  necrotic  centre  caused  in  the  kidney 
owing  to  the  occlusion  of  one  of  the  arterial  centres  b}^  the  anchoring 
suture.  A  similar  condition  has  been  noted  as  the  result  of  puncture. 
One  of  the  large  arteries  was  obstructed,  hgemorrhagic  infarction 
took  place,  and  ultimateh"  necrosis  (M'Ardle.  Brit.  Med.  Journ.,  vol.  i. 
1894,  p.  526).  A  fourth  step  that  has  been  advised,  scarifying  the 
surface  of  the  kidney  and  scraping  the  adjacent  muscles  andfasciaB 
does  not  commend  itself  to  me  as  satisfactory  at  the  time  or 
likely  to  be  of  permanent  utilit}^  later. 

To  speak  of  the  indications  more  exactly.  Where  an  otherwise 
health)^  kidney  is  verj^  movable,  especially  where  this  dates  in 
sensible  people  to  an  injury,  if  the  surgeon  is  in  doubt  as  to 
an  operation,  he  should  try  and  satisfy  himself  that  other  treatment, 
including  a  sufficient  trial  of  a  well-fitting  belt,  has  failed,  that  the 
pain,  whether  constant  or  paroxysmal,  is  hand  fide,  and  that  it  really 
cripples  and  spoils  the  patient's  life.  Constipation  and  dyspepsia 
will  of  course  have  been  treated,  tight  lacing  given  up,  and  a  trial 
made  of  a  well-fitting  belt,  or  a  corset  coming  low  down  in  front 
and  so  fitted  as  to  gather  up  the  lower  part  of  the  abdomen  and  its 
contents.  Thus,  conditions  of  movable  kidne}'  which  call  for  operation 
are  :  When  it  is  accompanied  by  undoubted  vomiting,  or  when,  on 
the  patient's  stooping,  the  viscus  comes  down  so  far  as  to  be  jammed 
between  the  ribs  and  the  crista  ilii. 

Another  strong  indication  for  nephrorraphy  is  early  hydronephrosis. 
Here  the  operation  is  resorted  to  not  only  to  save  the  patient  from 

*  Dr.  Newman  drew  attention  to  this  fact  several  years  ago  QLerts.  on  the  Surg, 
Sis.  of  the  Kidney,  p.  69) :  "  The  sutures  passed  into  the  kidney  became  destroyed 
more  rapidly  than  elsewhere  ;  the  living  renal  tissue  seems  to  have  an  iinusual  power 
of  absorption." 


NEPHRORRAPH  Y.  1 6  5 

the  pain  caused  b}-  the  movable  kidney,  but  to  "  prevent  the  organ 
from  bringing  about  its  own  destruction  "  (Lucas).  Mr.  Lucas  (Brit. 
Med.  Joarn.,  vol.  ii.  1891,  p.  1344)  relates  four  cases  in  which 
mobility  of  the  kidney  allowed  of  displacement  of  the  organ  on  its 
transverse  axis,  causing  bending  of  the  ureter,*  and  thus  distension  of 
the  pelvis  with  urine.  Two  of  the  cases  were  treated  by  nephrorraphy, 
and  when  last  seen  remained  cured.  One  of  the  cases,  in  which  the 
hydronephrosis  was  undoubtedl}'  due  to  the  displacement,  seemed  to 
show  that  the  destruction  of  the  kidney  may  occasionally  go  on  without 
any  severe  attacks  of  pain. 

The  following  questions  arise  as  to  the  sutures,  (i)  What  is  the  best 
material  ?     (2)  What  tissues  are  to  be  taken  up  ? 

The  answer  to  each  of  these  questions  is,  in  my  opinion,  a  simple 
one.  (i)  Silk,  which  is  easily  obtained  and  readily  sterilised,  with  a 
little  care  will  be  quite  eiHcient.  It  should  not  be  of  the  plaited 
kind,  it  should  be  of  medium  size  and  carefully  prepared.  Buried 
as  it  is  deeply,  the  use  of  silk  here  is  not  open  to  the  objections  to 
wdiich  I  have  alluded  in  the  account  of  Radical  Cure  of  Hernia. 
Kangaroo-tail  tendon  is  another  excellent  material. 

(2)  In  answer  to  this  question  I  am  strongly  of  opinion  that  to  ensure 
a  permament  cure  in  nephrorraphy,  the  sutures  should  take  hold  of  the 
proper  capsule  of  the  kidney  itself,  after  this  has  oeen  careful  peeled  off 
in  two  flaps.  I  have  tried  other  methods,  e.g.,  inserting  them  through 
the  substance  of  the  kidney  itself,  either  fastening  them  to  each  side  of 
the  wound  and  dropping  them  in,  or  passing  them  from  one  lip  of  the 
wound  through  the  kidney  and  finally  through  the  other  lip  of  the 
wound.  The  longer  I  watched  my  cases  the  less  reason  had  I  to  be 
satisfied,  though  the  earlier  results  had  been  excellent. 

I  have  used  the  following  method  in  fifteen  cases,  four  of  which 
were  bilateral.  One  case,  a  patient  of  Dr.  Brogden's,  of  Ipswich,  was 
operated  on  eleven  years  ago.  She  remains  well,  having  married  and 
had  a  child  since  the  operation.  Of  the  others,  in  one  only  do  I  kno^^- 
of  the  organ  becoming  loose  again,  a  patient  sent  to  me  by  Dr.  W.  A. 
Davies,  D.S.O.,-of  Johannesburg.  In  two  others,  owing  to  the  patients 
being  moved  too  soon,  the  wounds  reopened.  This  caused  considerable 
trouble. 

Operation. — The  kidney  is  first  thoroughly  exposed  by  the  steps 
given  at  p.  123,  an  assistant  keeping  the  organ  well  pushed  up  into 
the  loin  while  the  surgeon  cuts  down  on  it.  I  may  here  say  that  in 
some  of  these  cases  of  very  movable  kidney  the  tissues  around  are 
so  loose  from  the  dragging  and  shifting  to  and  fro  of  the  kidney  that 
they  wrap  round  the  organ  very  closely,  and  thus  it  is  easy  to  injure 
the  peritoneum.  Thus,  in  one  of  the  patients  mentioned  above  the 
right  kidney  was  mobile  through  an  extremely  wide  range,  and  so  loose 
that  when  lying  on  her  left  side  the  patient  could  make  it  project  as  a 

*  This  same  displacement  of  the  kidney,  which  occludes  for  a  time  the  ureter,  will 
also,  by  twisting  the  pedicle,  affect  its  vessels.  As  Mr.  Lucas  points  out,  the 
vein  will  suffer  more  from  pressure  than  the  artery,  thus  causing  turgcscence  of  the 
organ  generally  as  well  as  distension  of  its  pelvis.  Thus  are  brought  about  the  nausea, 
pain,  vomiting,  &c.,  which  have  been  described  as  strangulation  or  acute  dislocation 
of  the  kidiioy.  (Bruce  Clarke,  Trans.  Mcd.-Chir.  Soc  vol.  Ixxvi.  p.  263;  Brit.  Meri. 
Joiirn.,  vol.  i.  1895,  p.  575). 


1 66  OPERATIONS  OX  THE  ABDOMEN. 

convex  lump  in  the  left  iliac  fossa.  When  I  was  operating  on  this 
side  I  found  the  kidney  easily  reached,  but  not  easy  to  define,  owing  to 
the  extreme  looseness  of  the  folds  of  the  perinephritic  tissue  and  perito- 
naeum.* This  latter  structure  I  opened  in  two  places,  the  thin  edge  of 
the  liver  appearing  at  one,  and  some  omentum  in  the  other.  The  first 
opening  was  clamped  and  tied  up  with  a  catgut  ligature,  the  second 
closed  with  a  continuous  suture  of  the  same.  Strict  aseptic  precautions 
were  taken,  and  not  the  slightest  ill  result  followed. 

The  kidney  itself  having  been  exposed,  it  is  gently  withdrawn  through 
the  wound,  surrounded  with  aseptic  gauze  while  an  incision  is  made 
with  a  very  light  hand  all  along  the  convex  border  from  end  to  end. 
Unless  the  utmost  gentleness  is  taken  in  the  last  step  the  tissue  of  the 
organ  itself  will  certainly  be  incised,  causing  free  oozing.  With  the 
handle  of  a  scalpel  or  a  blunt  dissector,  flaps  of  capsule  are  then  deli- 
berately but  gently  stripped  oif  the  kidney  up  to  a  point  about  halfway 
along  its  lateral  surfaces,  so  as  to  raise  sufiicient  flaps  for  the  sutures  to 
find  a  holding  in.  The  flaps  having  been  raised  the}"  are  sutured  with 
medium-sized  sterilised  silk  to  the  aponeurotic  and  subcutaneous  edges 
of  the  wound.  To  get  a  firm  and  permanent  holding,  each  suture 
should  take  up  plenty  of  capsule  on  the  one  side  and  a  sufiicient  grip 
of  the  lumbar  fascia  on  the  other.  I  generally  use  upwards  of  twenty- 
sutures,  perhaps  twelve  in  one  flap  and  eight  in  the  other.  One  word 
of  caution  should  be  added.  This  method  of  anchoring  is  so  eflacient  that, 
iinless  care  is  taken,  it  is  joossible  to  fix  the  kidney,  which  has  been  drawn 
out,  actually  between  and  not  beneath  the  lips  of  the  wound.  After 
one  row  of  sutures,  say  the  upper,  has  been  inserted,  tied  and  cut  short, 
and  the  second  merely  inserted,  care  should  be  taken  gently  to  push  the 
kidney  into  its  proper  place  in  the  loin,  just  under  the  wound :  the  lower 
sutures  are  then  also  tied,  cut  short,  and  dropped  in.  Any  oozing  met 
with  after  stripping  off*  the  flaps  of  capsule  will  3'ield  to  firm  sponge- 
pressure  kept  up  by  an  assistant  while  the  surgeon  is  putting  in  his 
sutures.  It  is  well  also  to  keep  a  sponge  in  the  lower  part  of  the  wound, 
to  be  removed  before  the  last  sutures  are  tightened.  If  when  all  bleed- 
ing is  arrested  the  wound  is  very  carefully  dried  out  and  dusted  with 
sterile  iodoform,  no  drainage-tube  will  be  required.  In  closing  the 
wound  I  unite  the  edges  of  the  cut  lumbar  fascia  with  buried  sutures  of 
chromic  gut,  and  the  skin  with  salmon  gut.  I  recommend  this 
method  most  strongh* :  it  is  both  easy  and  efiicient,  and  sufiicient  time 
has  now  elapsed  in  several  of  my  cases  for  me  to  be  able  to  say  that 
no  injury  is  inflicted  on  the  kidney  by  the  stripping  off"  of  its  capsule. 
So  convinced  am  I  of  the  superiority  of  this  method  that  I  shall  not 
occupy  my  space  or  my  readers'  time  in  describing  any  other. 

*  This  was  not  a  mesonephron,  an  exceedingly  rare  condition.  I  find  that  Dr. 
Drummoiid,  of  Newcastle,  described  a  similar  condition  several  years  ago  ("  Clinical 
Aspects  of  Movable  Kidney,"  Lancet,  vol.  i.  1890,  p.  121)  :  "  In  almost  every  instance  in 
which  the  kidney  has  been  found  to  be  freely  movable,  the  other  abdominal  organs  have 
been  correspondingly  loose  in  their  attachments — the  spleen,  liver,  caecum,  stomach, 
&c.  More  than  once  a  distinct  mesonephron  was  present,  but  much  more  often  the 
peritonaeal  covering  was  simply  loose,  so  that  the  organ  could  be  easily  placed  in 
various  novel  positions.  At  times  the  kidney  had  dragged  the  relaxed  peritonaeum  so 
far  from  the  abdominal  wall  as  to  bring  into  close  conjunction  the  upper  and  lower 
layers,  so  as  to  form  a  false  mesonephron." 


OPEEATIONS  OX  THE  URETER.  167 


OPERATIONS    ON   THE    URETER. 

There  are  two  main  conditions  in  which  operations  on  the  ureter  are 
necessary : 

A.  Ureteral  Obstruction. 

B.  Injuries  to  the  Ureter. 

A.  Ureteral  Obstruction. — This  in  the  great  majority  of  cases  is  due 
to  the  impaction  of"  a  calcuhis  in  the  ureter;  in  others,  however,  it  has 
been  found  to  be  due  to  a  valvular  formation  at  the  opening  of  the 
ureter  into  the  renal  pelvis  or  to  a  stricture  of  the  ureter.  These  condi- 
tions will  be  considered  separately. 

I.  Ureteral  Calculus. — Impaction  of  a  calculus  may  take  place  at 
almost  any  point  in  the  course  of  the  ureter,  although  in  most  cases 
impaction  occurs  either  at  the  upper  extremity  of  the  ureter  close  to  the 
kidne}',  opposite  the  brim  of  the  pelvis,  or  at  the  vesical  orifice.  There 
can  be  no  doubt  whatever  that  in  many  cases,  where  a  renal  calculus  has 
been  diagnosed  and  no  calculus  found,  the  stone  has  really  been  in  the 
ureter.  With  more  thorough  exploration  of  the  ureter,  however,  in 
every  case  where  no  stone  is  found  in  the  kidney,  failure  of  the  operation 
from  this  cause  will  doubtless  be  prevented.  The  methods  of  dealing 
with  these  cases  will  now  be  considered  under  different  headings,  ac- 
cording to  the  site  of  impaction  of  the  calculus. 

I.  Impactio'ii  of  a  Calculus  at  or  above  the  Brim  of  the  Pelvis. — In  these 
cases  the  ureter  can  be  sufficiently  exposed  by  prolonging  the  incision 
already  made  for  exploring  the  kidney  as  above  described  (vide  p.  126). 

In  some  cases  the  dilatation  of  the  ureter  above  the  site  of  impac- 
tion will  allow  of  the  calculus  being  pushed  gently  along  the  ureter, 
either  up  to  the  kidney  or,  at  any  rate,  to  some  more  accessible  part  of 
the  ureter.  Tuffier  (Duplay  and  Reclus,  Traite  de  Chirurgie,  t.  vii.  1892), 
during  a  lumbar  nephro-lithotomy,  in  which  examination  of  the  kidney 
revealed  no  stone,  detected  a  hard  oval  body  about  three  centimetres 
long,  where  the  ureter  crossed  the  pelvis  brim.  The  stone  was  movable 
and  was  pushed  up  into  the  pelvis  of  the  kidney,  and  removed  by  an 
incision  into  the  convex  border.     The  patient  recovered. 

If  the  stone  cannot  be  pushed  up  as  far  as  the  kidney,  or  is  so  tightly 
impacted  that  it  cannot  be  moved,  it  should  be  removed  through  a 
longitudinal  incision  in  the  ureter.  The  incision  in  the  ureter  may  be 
sutured  with  fine  silk  or  catgut,  passing  through  the  outer  coats,  or  it 
may  be  left  without  sutures.  Should  inflammatory  thickening  or 
ulceration  of  the  ureter  be  present,  it  would  seem  wiser  not  to  insert 
sutures.  A  number  of  successful  cases,  both  \yiih.  and  without  sutures, 
have  been  recorded.  The  following  case,  described  by  Dr.  Kirkham 
(Lancet,  March  16,  1899).  is  an  illustrative  one.  and  is,  I  believe,  the  first 
case  in  which  a  patient  has  been  saved  from  death  from  suppression  of 
urine  by  the  removal  of  a  calculus  low  down  in  the  ureter: 

The  patient  was  58.  He  had  twice  suffered  from  right  renal  colic,  and  had  passed  a 
small  calculus.  May  24,  left  renal  colic  came  on.  No  urine  was  passed  from  this  date 
till  after  the  operation.  May  30,  the  patient  was  drowsy,  with  prostration  and  muscular 
twitchings.    Dr.  Kirkham  then  explored  the  kidney  in  the  hope  that  if  no  calculus  wa.s 


1 68  OPEEATIONS  ON  THE  ABDOMEN. 

removed  life  might  be  saved  by  affording  an  outlet  to  the  urine  by  an  incision  into  the 
jjelvis  of  the  kidney.  An  incision  was  made  from  the  tip  of  the  last  rib  towards  the 
anterior  superior  spine.  No  stone  being  found  in  the  kidney,  the  exploration  was  con- 
tinued along  the  ureter,  in  which  a  stone  was  distinctly  felt  about  half  an  inch  above 
where  the  ureter  crosses  the  external  iliac.  There  was  a  little  difficulty  in  reaching  the 
iireter  in  this  part  of  its  course,  but  after  enlargement  of  the  wound  a  calculus  about 
the  size  of  a  date-stone  was  removed.  A  little  urine  escaped  from  the  incision  into  the 
ureter.  No  sutures  were  placed  in  this.  Half  an  hour  after  the  operation  an  ounce 
and  a  half  of  urine  was  passed  naturally.  Very  little  escaped  from  the  wound  in  the 
ureter,  and  the  patient  made  an  excellent  recovery. 

2.  I'mpadion  oj  a  Calculus  in  the  Pelvic  Portion  of  the  Ureter. — In  the 
male,  the  greater  part  of  the  pelvic  ureter  can  be  exposed  by  a  prolonga- 
tion of  the  lumbar  incision  already  made  for  exploring  the  kidney  as 
recommended  by  Morris  (^cide  p.  126). 

Should  the  patient,  however,  be  fat,  and  the  lumbar  incision  already  very 
deep,  this  method  will  be  found  to  be  extremely  difficult.  In  such  cases, 
and  also  in  the  female,  the  abdomen  should  be  opened  by  an  incision  in 
the  semilunar  line  or  through  the  rectus  sheath.  In  most  cases  it  will 
then  be  found  possible  to  push  the  calculus  along  the  dilated  ureter  up  to 
or  near  the  kidney,  when  its  removal  can  be  accomplished  through  the 
lumbar  incision,  and  the  abdominal  wound  closed.  This  plan  was  first 
carried  out  by  Lane  in  the  following  case  (Lancet,  1890,  vol.  ii.  p.  967)  : 

A  woman,  aged  23,  had  had  symptoms  of  renal  stone  for  twenty  j'cars,  but  there  was 
nothing  to  point  to  the  fact  that  the  stone  was  in  the  ureter  and  not  in  the  kidney, 
except  that,  associated  with  her  renal  pain,  she  complained  at  times  of  pain  in  the 
lower  part  of  the  abdomen  on  the  same  side,  which  did  not  appear  to  be  reflected.  The 
kidney  was  explored  by  the  lumbar  incision,  and  nothing  found  either  in  this  organ  or 
in  those  parts  of  the  ureter  which  could  be  reached  from  above  or  per  Tectum.  The 
pain  having  returned  with  its  original  severity,  the  abdomen  was  opened  along  the  left 
liuea  semilunaris,  and  in  the  portion  of  the  ureter  which  had  not  been  explored  at  the 
previous  operation  a  small  stone  was  felt.  This  was  forced  upwards  along  the  ureter 
to  the  crest  of  the  ilium,  and  by  means  of  a  small  incision  in  the  side  the  ureter  was 
exposed  and  the  stone  removed.  The  aperture  in  the  ureter  was  sewn  up  by  a  fine  con- 
tinuous silk  suture.  No  leakage  took  place  from  the  ureter,  and  the  woman  recovered 
completely,  losing  all  her  pain  and  discomfort. 

It  may,  however,  be  found  impossible  to  push  the  calculus  u]-)  the 
iireter,  owing  to  firm  impaction  or  to  insufficient  dilatation  of  the  ureter 
above  the  calculus.  In  this  case  the  calculus  must  be  removed  through 
the  peritonaeum,  and  the  ureter,  if  possible,  sutured,,  drainage  in  case  of 
leakage  being  provided  for  by  means  of  a  tampon  of  iodoform  gauze.  In 
a  case  recenth"  operated  upon  by  one  of  us  (F.  J.  Steward,  Clin.  Soc. 
Trans.,  vol.  xxxiv.)  this  was  done,  and  the  ureter  and  peritonteum 
sutured  : 

The  patient  was  admitted  for  hematuria  and  painful  micturition,  which,  in  the 
absence  of  pain  or  tenderness  over  either  kidney  or  ureter,  were  thought  to  be  due  to 
a  vesical  calculus.  As  the  sound  detected  nothing,  the  bladder,  after  being  distended 
with  air,  was  opened  above  the  pubes.  Nothing  was  found  in  the  bladder,  but 
through  its  walls  a  stone  could  be  felt  in  the  lower  part  of  the  right  ureter.  As  the 
stone  could  not  be  worked  down  towards  the  bladder  the  wound  was  closed.  Eight  days 
later  an  incision  about  five  inches  long  was  made  in  the  lower  part  of  the  right  linea 
semilunaris  and  the  peritonseal  sac  opened.  The  stone  was  easily  felt,  and  was  gently 
manipulated  up  the  ureter  as  far  as  a  point  a  little  above  the  iliac  vessels.  As  it  would 
go  no  further,  the  peritonEeum  and  then  the  ureter  were  incised  and  the  stone,  weigh- 
ing nine  grains,  removed.     The  ureter  was  then  closed  with  a  fine  silk  suture,  taking 


OPERATIONS  ON  THE  URETER. 


169 


up  the  outer  coats  only;  the  peritouEeura  was  then  sutured  in  like  manner,  and  the 
wound  closed  with  the  exception  of  a  small  part  through  which  a  gauze  drain  was 
brought.     No  leakage  occurred,  and  the  patient  made  a  satisfactory  recovery. 

Other  methods  have,  however,  been  adopted.  Enimett  and  Cabot 
have  both  successfullj'  removed  ureteral  calculi  through  the  vagina, 
while  Ceci  records  a  successful  case  in  which  he  removed  the  stone 
through  the  rectum.  The  latter  method  cannot,  however,  be  con- 
sidered safe. 

3.  Impaction  at  the  Vesical  Orifice. — A  number  of  successful  cases  of 
removal  of  calculi  in  this  position  have  been  recorded.  This  has  been 
done,  in  the  female,  after  dilatation  of  the  urethra,  by  Emmett,  Berg, 
Eichmond,  Czernjr,  Sanger,  and  Thornton.  Tuffier  has  also  removed 
stones  in  this  position  twice  by  supra-pubic  cystotomy. 
^  II.  Valvular  Obstruction. — Simon,  in  1876,  gave  theoretical  direc- 
tions for  the  relief  of  this  condition ;  the  first  successful  operation  was. 


Fig. 


41. 


SiQE 


Tlhistratiug  Fenger's  operation  for  stricture  of  the  ureter.     (Morris.) 

however,  performed  by  Fenger,  of  Chicago,  in  1892.  The  method  of 
dealing  with  the  condition  ma}^  be  gathered  from  the  following  ?'esMHt6' of 
Fenger's  case  (Ann.  of  Sun/.,  vol.  xx.  1894).  The  patient  was  a  woman, 
aged  28,  with  intermittent  hydronephrosis  due  to  a  movable  kidney.  The 
pelvis  and  calyces  were  first  explored  and  no  stone  found.  As  the  ureter 
could  not  be  catheterised,  a  small  opening  was  made  in  the  posterior 
wall  of  the  infundibulum,  wlien  a  valvular  obstruction  was  found  at  the 
upper  end  of  the  ureter  where  it  joined  the  renal  pelvis.  The  valve  was 
divided  vertically,  and  the  ends  of  the  longitudinal  incision  united  by 
sutures,  so  as  to  convert  the  incision  into  a  transverse  one.  The  incision 
in  the  infundibulum  was  then  closed  with  sutures,  and  the  kidney  fixed 
in  the  loin,  a  bougie  being  passed  through  the  wound  in  the  renal 
parenchyma  and  retained  in  position  in  the  ureter  for  two  days.     The 


I/O  OPERATIOXS  OX  THE  ABDOMEN. 

patient  recovered  witliout  a  fistula,  and  subsequent!}'  liad  no  return  of 
the  hydronephrosis. 

III.  Stkictuke  of  the  Ureter. — Various  plans  have  been  adopted 
by  different  surgeons  to  remedy  strictures  of  the  ureter,  the  chief  being 
the  plastic  method  of  Fenger  (loc.  supra  cit.),  dilatation  by  bougies 
(Alsberg),  and  resection  of  the  strictured  portion  (Kuster).  The  first  of 
these  plans  only  will  be  here  described,  as  it  a^t.11  probably  be  found 
applicable  to  the  greatest  number  of  cases.  Moreover,  this  method  has 
been  successfully  carried  out  at  least  three  times  b}'  Fenger,  Morris,  and 
Mynter. 

The  details  of  the  operation  can  be  very  well  made  out  b}'  reference  to 
the  three  illustrations  in  Fig.  41.  The  strictured  portion  of  the  ureter  is 
first  divided  longitudinalh' ;  sutures  of  fine  silk  are  then  passed  on  either 
side  of  this  in  order  to  draw  the  two  extremities  of  the  incision  together 
and  thus  convert  it  into  a  transverse  one,  after  the  manner  of  the 
Heineke-Mickulicz  operation  for  stenosis  of  the  pylorus.  Further 
sutures,  passing  through  the  outer  coats  only,  now  bring  the  edges  of 
the  rest  of  the  incision  together,  thus  folding  the  ureter  on  itself  to 
some  extent. 

The  following  short  account  of  Fenger's  case  well  illustrates  the 
brilliant  success  of  the  operation  : 

"  Traumatic  stricture  of  ureter  close  to  entrance  into  pelvis  of  kidney; 
intermittent  pyonephrosis  for  twenty-four  years  ;  increased  frequency  of 
attacks.  Nephrotomy ;  no  stone  in  sacculated  kidney,  ureteral  entrance 
could  not  be  found ;  longitudinal  ureterotomy  revealed  stricture  at 
upper  end  of  ureter ;  longitudinal  division  of  stricture  and  plastic 
operation  on  ureter.     Recovery  without  fistula." 

B.  Injuries  to  the  Ureter. — These  may  be  met  with  either  in  the 
form  of  traumatic  ruptures,  or  of  accidental  division  or  removal  of  a 
piece  of  the  ureter  during  the  course  of  certain  abdominal  operations, 
such  as  hj'sterectoni}'  or  the  removal  of  a  pelvic  tumour. 

Traumatic  rupture  of  the  ureter  has  not  yet  been  treated  by  direct 
suture.  This  is  owing  doubtless  to  the  extreme  difficulty  in  the  diagnosis 
of  tliis  condition  in  the  earl}'  stages,  for  most  of  the  cases  have  not  been 
recognised  until  an  accumulation  of  urine,  blood,  or  pus  has  formed  and 
has  been  opened.  The  tumour  due  to  the  accumulation  may  not  be 
noticed  for  some  time,  two  to  three  weeks  (Stanley,  Page,  Barker, 
Hicks),  thirty-nine  days  (Croft),  and  in  one  case  (Stanley's)  not  until 
seven  weeks  after  the  injury. 

For  accidental  di\'ision  or  removal  of  a  piece  of  the  ureter  during  the 
course  of  an  abdominal  operation,  a  very  large  number  of  different 
operations  have  been  performed.  It  is  impossible  here  to  mention  or 
describe  all  these  operations.  An  attempt  will,  however,  be  made  to 
indicate  the  methods  which  are  likely  to  be  found  most  suitable  to  the 
various  conditions  that  may  be  met  with. 

In  the  great  majorit}^  of  instances  it  will  be  found  possible  to  directly 
unite  the  divided  ends  of  the  ureter.  The  results  that  have  so  far 
attended  the  various  methods  of  bringing  this  about  clearly  show  that  it 
should  be  done  wherever  possible.  Bovee  (Ann.  of  Surg.,  Aug.  1900) 
mentions  twenty-seven  published  cases  with  only  two  deaths,  and  not  in 
one  was  thei*e  failure  to  unite.  If  the  ureter  has  been  simph*  divided 
without  loss  of  substance,  and  if  both  the  ends  are  accessible  and  the 


OPERATIONS  OX  THE  URETER. 


171 


upper  end  A\-ill  not  reach  the  bladder,  then,  because  it  is  the  most  simple 
method  to  carry  out,  and  because  it  is  the  least  likely  to  be  followed  by 
stricture,  the  following  operation,  devised  by  Van  Hook  (vide  Fig.  42), 
should  be  performed.  The  following  are  the  steps  of  the  operation  as 
given  by  Fenger  (Joe.  supra  cit.)  : 

"  (i)  Ligate  the  lower  portion  of  the  tube  one-eighth  or  one-fourth 
of  an  inch  from  the  free  end.  Silk  or  catgut  may  be  used.  Make  ^vith 
fine  sharp-pointed  scissors  a  longitudinal  incision,  twice  as  long  as  the 
diameter  of  the  ureter,  in  the  wall  of  the  lower  end,  one-fourth  of  an 
inch  below  the  ligature. 

"  (2)  Make  an  incision  with  the  scissors  in  the  upper  portion  of  the 
ureter,  beginning  at  the  open  end  of  the  duct  and  carrying  it  up  one- 
fourth  of  an  inch.     This  incision  ensures  the  patency  of  the  tube. 

Fig.  42. 


Uretero-ureterostomy.     Van  Hook's  method.     (Morris.) 


"  (3)  Pass  two  very  small  cambric  sewing  needles  armed  with  one 
thread  of  sterilised  catgut  through  the  wall  of  the  uj^per  end  of  tha 
ureter,  one-eighth  of  an  inch  from  the  extremity,  from  within  outward, 
the  needles  being  from  one-sixteenth  to  one-eighth  of  an  inch  apart,  and 
equidistant  from  the  end  of  the  duct.  It  will  be  seen  that  the  loop  of 
catgut  between  the  needles  firmly  grasj)S  the  upper  end  of  the  ureter. 

"  (4)  These  needles  are  now  carried  through  the  slit  in  the  side  of  the 
lower  end  of  the  ureter  into  and  down  the  tube  for  one-half  an  inch, 
Avhere  they  are  pushed  through  the  wall  of  the  duct  side  by  side. 

"  (5)  It  will  now  be  seen  that  traction  upon  this  catgut  loop  passing 
through  the  wall  of  the  ureter  will  draw  the  upper  fragment  of  the  duct 
into  the  lower  portion.  This  being  done,  the  ends  of  the  loop  are  tied 
together  securely,  and  as  the  catgut  will  be  absorbed  in  a  few  days, 
calculi  do  not  form  to  obstruct  the  passage  of  the  urine. 


172 


OPERATIONS  OX  THE  ABDOMEN. 


'•  (6)  The  ureter' is  now  enveloped  carefully  with  peritonaeum." 
If,  however,  a  portion  of  the  ureter  has  been  accidentally  removed, 
and  the  upper  end  will  not  reach  the  bladder,  it  will  probably  be  found 
that  there  will  not  be  sufficient  length  of  ureter  available  for  performing- 
Van  Hook's  operation.  In  this  case  the  ends  must  be  united  by  end-to- 
end  suture,  or  by  the  oblique  method  of  Bovee  {vide  Fig.  43). 

Should  it  be  found  that  the  upper  end  of  the  divided  ureter  will  reach 
the  bladder,  implantation  into  this  organ  is  preferable  to  all  other 
procedures.  This  may  be  carried  out  by  the  method  of  Paoli  and 
Busachi  (Anncdes  cles  Maladies  des  Organes  Genito-urinaires,  1888), 
which  consists  in  splitting  the  distal  end  of  the  in-eter  and  uniting  it 
by  sutures  to  an  incision  in  the  bladder,  or  by  a  modification  of  the 
operation  of  Van  Hook  for  uretero-ureterostomy,  the  cut  end   of  the 

Fig.  43. 


Uretero-ureterostomj-.     To  illustrate  the  oblique  ir.etliocl  of  Bovee. 
(Morris.) 

ureter  being  invaginated  into  the  bladder.  This  method  has  been 
adopted  by  Penrose  and  others  {Med.  Ne^is,  vol.  Ixiv.,  1894,  p.  470). 
Finally,  should  such  a  length  of  ureter  have  been  removed  as  to 
render  both  direct  union  of  the  two  ends  and  implantation  into  the 
bladder  impossible,  the  proximal  end  must  be  either  implanted  into  the 
bowel  or  on  the  skin.  The  results  of  both  these  plans  have  so  far  been 
on  the  whole  extremely  unsatisfactor}',  owing  to  infection  of  the  ureter 
and  kidney  in  the  case  of  implantation  into  the  bowel,  and  to  discomfort 
and  constant  irritation  of  the  skin  when  the  implantation  is  made  on 
the  skin.  For  these  reasons  a  secondary  nephrectomy  will  nearly  alwaj^s 
be  necessary  in  such  cases. 


CHAPTER    V. 
OPERATIONS   ON   THE   INTESTINES. 

ACUTE  INTESTINAL  OBSTRUCTION.  —  APPENDICITIS.  — 
PERFORATING  ULCER  OF  STOMACH— OF  DUODENUM 
—OF  INTESTINE  AFTER  TYPHOID  FEVER.— SUPPURA- 
TIVE PERITONITIS.  ~  TUBERCULAR  PERITONITIS.  — 
ENTEROSTOMY.— FORMATION  OF  ARTIFICIAL  ANUS.— 
SUTURE  OF  INTESTINE.— RESECTION  OF  INTESTINE. 
—ENTERECTOMY.— COLECTOMY.  — INTESTINAL  ANAS- 
TOMOSIS AND  SHORT  CIRCUITING.— ENTEROPLASTY.— 
CLOSURE  OF  ARTIFICIAL  ANUS  AND  FJECAL  FISTULA. 

ACUTE    INTESTINAL    OBSTRUCTION. 

Considered  generally,  without  reference  to  the  causation  of  the 
obstruction,  the  successful  treatment  of  acute  intestinal  obstruction 
depends  largeh"  on  two  points :  («)  The  Question  of  Operation, 
and  (h )  The  Question  of  the  Extent  of  Interference  that  is  indicated 
in  any  given  Case. 

(a)  The  Question  of  Operation. — Although  cases  of  so-called  "  spon- 
taneous cure "  have  from  time  to  time  been  recorded,  the  number  of 
these  is  so  small,  and  the  correctness  of  the  diagnosis  in  many  of  them 
so  doubtful,  that  for  all  practical  purposes  it  is  wiser  to  leave  them 
entirel}^  out  of  consideration.  For,  apart  from  these  and  the  small 
number  of  cases  of  intussusception  that  have  survived  the  sloughing  of  the 
intussusceptum,  as  Sir  F.  Treves  saj^s,  "  there  is  no  avoiding  the  fact  that 
acute  intestinal  obstruction,  if  unrelieved,  ends  in  death  "  (Intestinal 
Ohstruction,  p.  475).  This  being  so,  it  clearly  becomes  the  dutj-  of  the 
surgeon  to  operate  on  ever^'  case  of  acute  intestinal  obstruction.  The 
operation,  moreover,  should  be  performed  at  the  earliest  possible  moment 
after  the  diagnosis  has  been  made,  for,  serious  as  the  operation  is  in 
itself,  it  is  not  nearly  so  serious  as  delay,  since  the  mortality  rises 
extremely  rapidly  as  the  period  between  the  onset  of  the  sj'mptoms  and 
the  time  of  operation  increases.  Neither  should  uncertainty  of  dia- 
gnosis be  allowed  to  delay  the  operation,  for  of  the  many  conditions  that 


174  OPERATIONS  OX  THE  ABDOMEN. 

simulate  acute  intestinal  obstruction — e.g.,  typhlitis  and  appendicitis, 
peritonitis  from  different  causes,  thrombosis  of  mesenteric  veins,  acute 
pancreatitis,  enteritis,  &c. — in  some  an  operation  may  be  beneficial, 
while  as  to  the  others  it  would  be  better  that  an  exploratory  operation, 
as  long  as  it  is  done  by  skilled  hands,  took  place  needlessly  than  that  a 
remediable  condition  should  be  left  untouched.  Here,  again,  the  valuable 
opinion  of  Sir  F.  Treves  may  be  quoted.  He  says  :  "  Operation  in  these 
cases  is  too  often  regarded  as  a  last  resource.  It  should  be  the  first- 
resource,  as  it  certainh*  is  the  oiilij  resource." 

The  mortality  of  all  cases  of  acute  intestinal  obstruction  at  the  present 
time,  as  shown  by  Gibson  {Ann.  of  Surg.,  Oct.  1900)  in  a  collection  of 
cases  operated  upon  between  1888  and  1898,  is  about  47  per  cent.,  his 
list  including  646  cases  with  312  deaths;  and  although  this  is  without 
doubt  a  vast  improvement  upon  former  times,  it  is  still  to  be  hoped  that 
in  the  near  future  earlier  recognition  and  more  immediate  operation  will 
do  much  to  bring  about  still  further  improvement.  Even  then  the 
mortality  will  probably  always  be  high,  and  this  owing  to  the  frequently 
complicated  nature  of  the  cause  of  the  obstruction,  the  peculiar  vitalitj' 
of  the  parts  which  have  to  be  handled,  and  the  readiness  with  which 
these  pass  into  a  condition  beyond  recovery.  Bearing  in  mind,  however, 
the  essentialh'  fatal  character  of  the  condition,  apart  from  relief  by 
operation,  every  successful  operation  should  be  looked  upon  rather  as  a 
life  saved,  than  every  fatal  one  as  a  life  lost. 

(/>)  The  Extent  of  Interference  that  is  indicated  in  a  given  Case. 
— The  operation  must  be  according  to  the  state  of  the  patient.  These 
cases  of  acute  intestinal  obstruction  are  not  to  be  grouped  together  as 
all  equally  fit  for  operation,  or  as  all  certain  to  be  relieved  by  operation 
as  long  as  this  is  undertaken  earh^.  In  some  the  condition  of  the  patient 
is  good,  the  abdomen  is  undistended  and  a  prolonged  search  may  be 
made.  In  others  a  precisel}'  opposite  condition  is  present,  any  prolonged 
exploration  is  out  of  the  question,  and  all  that  can  be  done,  if  the  cause 
is  not  found  at  once,  is  to  open  one  of  the  most  distended  coils,  as  low 
down  as  possible,  and  drain  the  intestines  {vide  infra). 

I  propose  to  describe  the  operation  generally  first,  and  then  to  allude 
to  its  application  to  the  chief  forms  of  acute  intestinal  obstruction. 

Operation. — The  bladder  is  first  emptied,  and  the  abdominal  wall 
shaved  and  cleansed,  A  water-bed  should  be  filled  with  hot  water, 
and  if  the  patient's  condition  is  bad,  a  hot  port  wine  enema  should 
be  given. 

The  question  of  anaesthetics  in  these  cases  is  a  very  important  one, 
and  should  be  well  considered.  The  impeded  respiration  due  to  the 
abdominal  distension  is  liable  to  make  the  administration  of  a  general 
anassthetic  difficult  and  dangerous.  The  tendency  to  vomit  is  another 
grave  danger,  a  sudden  attack  during  the  administration  having  fre- 
quently caused  immediate  death  from  choking. 

Apart  from  these  two  considerations,  the  administration  of  a  general 
anaesthetic  seems  to  have  special  dangers  of  its  own  in  cases  of  acute 
intestinal  obstruction,  for  it  undoubtedly  often  produces  a  complete  and 
sudden  change  in  the  Avhole  aspect  of  a  case,  a  patient  thought  to  be  in 
good  condition  and  well  able  to  bear  an  operation  becoming  suddenly 
moribund  within  a  few  minutes  of  the  commencement  of  [the  adminis- 
tration. 


ACUTE  INTESTINAL  OBSTRUCTION.  175 

For  all  these  reasons  it  is  achasable,  wherever  possible,  and  espe- 
cially in  very  bad  cases,  to  make  use  of  local  anajsthesia  only,  the 
infiltration  method  of  Schleich  with  cocaine,  or  y3  eucaine,  being  the  most 
suitable. 

Should  it,  however,  be  deemed  inadvisable  to  operate  without  general 
anesthesia,  the  stomach  should  be  previously  washed  out  if  vomiting  has 
been  severe,  and  saline  infusions,  either  intra- venous  or  into  the  cellular 
tissue  of  the  axilla,  should  be  made  as  soon  as  possible  after  the  adminis- 
tration of  the  ana3sthetic  has  been  begun. 

The  operation  to  be  performed  ^^^ll  necessarily  vary  according  to  the 
general  condition  of  the  patient,  and  the  mode  of  procedure  will  be 
described  under  two  heads :  (A)  Early  Cases,  or  where  the  condition 
of  the  patient  is  good  ;  and  (B)  Late  Cases,  or  where  the  condition 
of  the  patient  is  very  serious. 

(A)  The  surgeon  makes  a  central  incision,*  beginning  two  inches 
above  the  umbilicus,  and  passing  to  the  left  of  this  he  gains  the  middle 
line  to  descend,  going  quickly  down  to  the  peritonseum,  but  arresting 
all  haemorrhage  before  this  is  opened.  If  the  linea  alba  is  not  hit  off 
exactly,  and  is  not  qiiickly  found,  any  muscular  fibres  are  torn  straight 
through  with  a  steel  director,  and  the  transversalis  fascia  and  peritoneum 
thus  reached. 

I  strongly  advise  the  sm-geon  to  give  himself  plenty  of  room,  so  as  to 
quickly  get  his  hand  in  and  explore  efiiciently.  A  short  median  incision 
below  the  umbilicus,  and  the  introduction  of  a  couple  of  fingers,  is 
usually  futile.  The  abdominal  wall  in  these  cases  is  not  thinned  and 
overstretched  as  in  ovariotomy ;  hence,  if  inadequately  opened,  it  grips 
the  hand  most  embarrassingly.  If  the  case  has  been  allowed  to  go  on 
until  the  intestines  are  distended,  the  search  for  the  cause  of  the  mischief 
will  be  rendered  all  the  more  difiicult,  and  there  must  be  sufficient  room 
to  introduce  the  hand  freely.  If  an  assistant  skilfully  keeps  the  edges  of 
the  wound  together  where  this  is  not  occupied  by  the  inserted  Avrist,  the 
intestines  will  not  escape. 

The  peritonaeum  should  alwaj'S  be  well  lifted  up  before  it  is  opened, 
especially  if  there  is  distended  bowel  beneath.  The  opening  is  then 
enlarged  with  a  blunt-pointed  bistoury  or  scissors,  two  fingers  with  the 
palmar  aspect  turned  upwards  serving  now  as  the  best  director. 

The  late  Mr.  Greig  Smith  advised,  where  the  peritoneum  is  thin,  that 
it  be  pinched  up  between  the  finger  and  thumb,  and  rolled  about  to  see 
that  no  bowel  is  included. f 

The  surgeon  should  now  decide  Avhicli  mode  of  exploration  he  will 
make  use  of.  The  following  is  as  useful  as  any:  If  the  parts  are  not 
much  distended,  three  possible  sites  of  strangulation  should  be  first 
looked  to.      (i)  The  c£ecum,:J:  which  will  give  twofold  evidence,  first,  its 

*  Tn  those  extremely  rare  cases  where  the  obstruction  can  be  localised  to  one  or  other 
side  of  the  abdomen,  a  lateral  incision  may  be  made  use  of,  either  over  the  swelling,  if 
auj'  be  present,  or  in  the  linea  semilunaris. 

t  If  much  fluid  is  present,  it  now  often  shows  itself  through  the  peritoneum. 

X  If  the  cecum  can  be  made  out  to  be  empty,  tracing  up  empty  coils  from  this  will 
very  likely  lead  to  the  obstruction.  The  more  marked  the  evidence  of  collapsed  small 
intestine,  the  greater  the  probability  of  the  obstruction  being  high  up,  and  the  less  fit 
the  case  for  enterostomy  (p.  221)  (R.  Jones.  Urit.  Med.  Journ.,  vol.  i.  1894,  p.  1123). 
In  this  case  a  baud  was  found  and  successfully  dealt  with.     Here  the  obstruction  had 


176  OPERATIONS  ON  THE  ABU03IEN. 

distension  or  emptiness  telling  whether  the  obstruction  is  above  or  below 
it ;  and  secondly,  the  state  of  its  appendix,  whether  normal  or  adherent, 
whether  empty  or  containing  some  concretion.  (2)  Next,  the  internal 
inguinal,  the  femoral,  and  obtui'ator  rings  are  explored,  to  make  sure 
that  no  tiny  hernia  exists,  imperceptible  from  the  outside.  The  fingers 
are  next  swept  upwards  towards  the  (3)  umbilicus,  in  the  hope  of  finding 
one  of  the  diverticular  bands  mentioned  at  p.  179.  If,  up  to  this,  the 
search  has  been  fruitless,  the  brim  of  the  pelvis  is  next  examined,  as 
bands  of  omenta  are  often  fixed  hereabouts,  and  also  because,  in  women, 
local  peritonitis,  originating  about  the  uterus  or  its  appendages,  and,  in 
either  sex,  about  the  appendix  cteci,  is,  not  infrequently,  the  cause  of 
the  obstruction. 

If  the  search  fail — and  it  often  will  when  distension  is  present,  embar- 
rassing the  fingers  in  their  movements,  and  obscuring  the  relation  of 
parts — one  or  two  of  the  loops  which  lie  nearest  to  the  wound  should  be 
carefully  scrutinised.*  These  should  be  followed  in  the  direction  of 
increasing  congestion  and  distension,  thus  leading  to  the  obstruction. 
Fixity  of  a  coil  may  be  another  aid.  Where  there  is  ground  to  believe 
that  the  case  may  be  one  of  acute  supervening  upon  chronic  obstruction, 
the  sigmoid  and  colon  should  be  first  investigated. 

If  this  prove  fruitless  in  cases  where  there  is  not  much  distension,  the 
plan  adopted  b}^  Mr.  Cripps  {Clin.  Soc.  Trans.,  vol.  xi.  p.  225)  is  the 
simplest — i.e.,  to  draw  out  some  inches  of  intestine  at  a  time,  bit  by  bit, 
from  the  upper  part  of  the  wound,  passing  it  in  again  into  the  belly 
through  the  lower  part,  in  such  a  way  that  at  no  time  are  more  than 
five  or  six  inches  of  intestine  exposed.  After  drawing  out  and  replacing 
some  feet  of  intestine  in  this  way,  it  is  probable  that,  owing  to  the 
increasing  congestion  or  I'esistance,  the  surgeon  will  reach  the  obstruc- 
tion.! This  is,  however,  a  tedious  method,  and  one  only  to  be  adopted 
when  the  condition  of  the  patient  is  good. 

An  assistant  should  hold  the  coil  from  which  the  surgeon  starts  in  the 
lower  angle  of  the  wound  under  a  hot  sponge,  so  as  to  save  the  surgeon 
going  over  the  ground  a  second  time. 

If  a  search  for  ten  minutes  has  failed  ;J:  to  find  the  cause  of  obstruction 
the  following  courses  remain  open :  (a)  Kummell's  plan  of  allowing  the 
small  intestines  to  prolapse  under  hot  aseptic  towels ;  {j3)  empt3ang  the 
most  distended  coil,  and  either  closing  the  opening  later,  or  (7)  inserting 
in  it  a  Paul's  tube  ;  (S)  "  short-circuiting." 

(a)  The  objection  to  this  method  is,  of  course,  that  it  is  often  exceed- 

been  incomplete  at  first,  one  of  incarceration  followed  by  strangulation.  I  have  men- 
tioned a  similar  successful  case  at  p.  278. 

*  The  late  Mr.  Greig  Smith  said  that  as  the  most  distended  coils  will  rise  nearest  the 
surface,  and  the  greater  amount  of  bowel  is  within  three  inches  of  the  umbilicus,  there 
is  a  probability  that  the  most  dilated  coils  will  be  in  sight. 

f  If  he  find  that  the  bowel  is  getting  healthier  and  emptier,  the  surgeon  must  reverse 
the  direction  of  his  search. 

J  "  The  difficulty  of  finding  the  obstruction  in  some  cases  is  well  shown  by  Madelung, 
who,  in  several  cases  where  the  seat  of  obstruction  could  not  be  located  during  life, 
requested  the  pathologist,  when  he  made  the  post-mortems,  to  locate  the  obstruction 
hy  introducing  his  hand  through  an  incision,  allowing  him  from  ten  to  twenty  minutes 
for  the  exploration ;  in  every  instance  he  failed  to  find  the  obstruction  within  the 
specified  time  "  (Senn,  loc.  svpra  cit.'). 


ACUTE  INTESTINAL  OBSTRUCTION.  1 77 

ingly  difSciilt  to  get  the  distended  coils  back  into  their  home,  and  that 
the  necessaiy  manipulations  and  exposure  must  produce  shock,  and  may 
inflict  serious  damage.  If,  however,  the  condition  of  the  patient  is  satis- 
factory and  the  amount  of  distension  not  great,  it  is,  if  done  properly, 
and  with  care  to  prevent  undue  exposure  of.  and  damage  to,  the  intes- 
tines, perhaps  the  wisest  course  to  pursue.  This  practice  is.  moreover, 
recommended  by  no  less  an  authority  than  Sir  F.  Treves,  who  considers 
that  the  damage  done  to  the  intestines,  by  the  amount  of  exposure 
necessary,  is  probably  less  than  that  caused  by  prolonged  manipulations 
within  the  abdominal  cavity.  The  abdominal  incision  should  be  made  very 
free,  and  the  intestines  then  allowed  to  escape  between  smooth-surfaced 
sterile  towels,  wrung  out  of  salt  solution  at  a  temperature  of  110°  F. 
In  this  wa}*  the  intestines  can  be  immediately  covered  with  the  towels. 
and  the  farther  search  for  the  cause  of  obstruction  conducted  with  ver}' 
little  exposure  or  interference.  Usually  the  seat  of  obstruction  will  be 
quickly  indicated  by  fixity  of  some  loop  of  intestine,  which  thus  will  not 
leave  the  abdomen. 

(/S)  Should,  however,  the  amount  of  distension  be  considerable,  it  is 
wiser  to  relieve  this  condition  before  proceeding  further.  To  this  end  a 
different  method  must  be  adopted  according  to  the  seat  of  greatest  dis- 
tension. Should  this  be  the  large  intestine,  for  instance,  in  a  case  of 
volvulus,  the  distended  loop  may  be  emptied,  either  by  multiple  puncture 
with  a  very  fine  h}"drocele  trocar  if,  which  is  rare,  they  contain  only  gas, 
or  by  incision  if  liquid  ffeces  are  present  as  well.  Both  these  steps  are 
often  disappointing.  Two  conditions  must  be  present  to  allow  multiple 
punctures  "with  the  finest  hydrocele  trocar  to  be  safe.  The  coats  of  the 
intestine  must  be  sufficiently  healthy,  neither  infiltrated  nor  paralysed, 
to  allow  the  peritonteal  and  muscular  coats  to  close  the  opening  in  the 
mucous  by  gliding  over  it,  otherwise  a  fatal  leakage  will  take  place 
iiaUatira  imless  every  puncture  is  closed  by  a  fine  parietal  suture. 
The  second  condition  is,  that  gas  only  must  be  present ;  liquid  faeces 
being  almost  invariably  present  as  well.  A  wiser  course  is  to  incise 
and  evacuate  the  most  distended  coils.  The  patient  being  turned  on 
to  one  side,  the  most  distended  loop  is  drawn  out  over  a  basin,  incised 
parallel  to  its  long  axis  at  a  point  most  distant  from  the  mesentery,  the 
rest  of  the  coils  being  kept  within  the  abdomen,  and  the  one  withdrawn 
carefully  isolated  by  tampons  of  iodoform  gauze  or  hot  aseptic  towels. 
As  the  escape  of  gas  and  fluids,  owing  to  the  paralysis  of  the  intestine, 
will  probably  be  very  slow,  it  will  be  wise  to  follow  Dr.  Senn,  and 
^'  resort  to  pouring  out  the  contents,  as  it  were,  by  seizing  the  gut 
several  feet  above  and  below  the  incision,  and  elevating  it,"  a  large 
quantity  of  fluid  fieces  being  thus  poured  out.  This  emptying  of  dis- 
tended coils  will  not  only  facilitate  reduction,  but.  as  first  urged  by  the 
late  Mr.  Greig  Smith  (Abdom.  Siirg.,  p.  436),  it  will  diminish  the  harmful 
effects  of  a  greatly  distended  abdomen,  viz.,  dyspnoea,  palpitation,  and 
abdominal  shock,  and,  as  regards  the  bowels  themselves,  the  danger  of 
continued  distension,  paralysis,  and  absorption  of  toxic  products.  When 
the  evacuation  has  been  made  as  complete  as  possible,  the  next  step  will 
depend  upon  the  condition  of  the  patient.  If  this  be  good,  and  the 
relief  of  the  distension  has  been  sufficient  to  justify  further  exploration, 
the  surgeon  closes  his  incision  in  the  intestine  by  Lembert's  sutures, 
taking  care  to  efiect  real  inversion  of  the  edges,  and,  leaving  one  or  two 
VOL.  II.  12 


178  OPERATIONS  ON  THE  ABDOMEN. 

of  the  sutures  long,  keeps  this  bit  of  intestine  outside,  entrusted  to  an 
assistant,  while  he  continues  his  search  for  the  cause  of  the  obstruction. 
If  this  be  found  and  removed,  the  opened  and  sutured  part  of  the 
intestine  must  again  be  inspected,  and  its  exact  closure  made  sure 
of  before  it  is  returned ;  any  sutures  left  long  having  been  first  cut 
short.  Before  finally  closing  the  wound  the  question  of  cleansing  the 
peritonteal  cavity,  irrigation,  and  the  insertion  of  a  Keith's  tube  into 
Douglas's  pouch  may  arise. 

If,  on  the  other  hand,  it  is  found  that  the  small  intestine  is  the  seat 
of  most  distension,  then  very  little  advantage  will  be  gained  by  either 
puncture  or  incision,  for  the  acute  flexures  caused  by  the  distension  will 
prevent  more  than  a  very  small  portion  of  the  gut  being  emptied  by 
each  incision.  In  this  case  it  is  wiser  to  drain  the  intestine  for  a 
time  by  performing  enterotomy,  as  described  below  (p.  222),  and  to 
search  for  and,  if  possible,  remove  the  cause  of  obstruction  after 
the  worst  of  the  distension  has  been  relieved. 

(7  and  S)  Where  the  patient's  condition  makes  any  further  search 
impossible,  or  where  there  is  great  distension,  a  temporary  or  permanent 
artificial  anus  must  be  made,  or  else  "short-circuiting"  must  be 
performed. 

As  the  last  can  very  rarely  help  us  in  acute  intestinal  obstruction,  I 
will  first  dispose  of  this  subject.  It  will  be  remembered  that  I  am 
speaking  of  short-circuiting  as  one  of  the  courses  open  to  a  surgeon 
when  he  fails  to  find  the  cause  of  an  acute  intestinal  obstruction,  or 
rather,  of  an  acute  supervening  upon  a  chronic  obstruction.  It  is 
evident  that  it  is  only  to  a  few  cases  that  this  method  is  suitable — e.g., 
cases  of  matting  together  of  coils  of  small  intestine,  as  after  previous 
mischief  set  up  by  a  mesenteric  gland,  or  appendicitis.  In  such  cases 
if  there  is  inextricable  matting  but  no  recent  inflammatory  changes  and 
nothing  like  gangrene,  a  coil  of  the  distended  small  intestine  may  be 
short-circuited  to  the  most  conveniently  placed  piece  of  large  intestine. 
This  is  effected  by  the  use  of  a  Mayo-Robson's  bobbin.  Murphy's  button, 
or  Senn's  plates  (q.r.),  according  to  the  surgeon's  familiarity  with  each, 
and  the  time  at  his  disposal.  In  the  majority  of  cases  where  the  surgeon 
cannot  find  the  cause,  some  part  of  the  small  intestine  will  be  suffering 
not  from  chronic  matting  as  above,  but  from  the  pressure  effects  of  some 
band,  orifice  in  the  omentum,  &c.,  and  softening,  or  even  gangrene,  may 
be  impending ;  then  a  better  plan  to  relieve  the  distended  intestine  will 
be  by  performing  enterotomy  as  described  below,  by  tying  in  a  Paul's 
tube,*  or  puncturing  with  a  large  trocar  and  cannula  (p.  223)  one 
of  the  most  distended  coils,  this  being  first  withdrawn  and  com- 
pletely isolated  with  sterilised  towels  or  iodoform  gauze.  While  the 
distension  is  being  relieved  the  parietal  wound  may  be  sutured,  and 
the  knuckle  of  projecting  bowel  attached  by  a  few  points  to  the  edges 
of  the  wound. 

The  peritonasal  sac  must  be  next  cleansed  of  any  fluids,  and  above  all 
of  any  discharges,  either  b_y  sponges  introduced  on  large  Spencer  Wells's 
forceps  down  into  the  pelvis  and  along  the  costo-vertebral  furrows,  or  by 

*  I  have  recorded,  pp.  226,  278,  a  case  in  which  this  treatment  saved  the  life  of  a, 
patient  suffering  from  strangulation  of  the  small  intestine  (localised  gangrene  having 
set  in)  by  a  band. 


ACUTE  INTESTINAL  OBSTRUCTION.  1 79 

flushing  with  a  hot  solution  of  boracic  acid  (2  per  cent.)  or  ^  per  cent, 
of  salicylic  acid,  in  boiled  water ;  pints  of  this  being  introduced  by  an 
irrigating  tube.  After  the  flushing,  sponges  are  again  used,  and  a 
Keith's  tube  inserted.  Drainage  is  always  to  be  emploj^ed  when  the  peri- 
tonaeal  sac  has  been  contaminated.     Further  details  are  given  at  p.  215. 

The  opening  in  the  abdominal  walls  is  then  closed  with  sutvires  of 
wire,  or  silk  or  fishing  gut.  material  of  sufficient  stoutness  being  pro- 
vided if  any  tension  is  present.  Care  should  be  taken  to  include  the 
parietal  peritongeum,  and,  as  the  sutures  are  inserted,  to  prevent  any 
blood  entering  the  cavity  of  the  peritonaeum. 

B.  Late  Cases. — Here  the  condition  of  the  patient  will  not  allow  of 
any  but  the  briefest  operation.  A  small  incision,  two  inches  long, 
is  made  in  the  median  line  below  the  umbilicus.  On  opening  the  perito- 
ngeum. two  fingers  are  introduced  and  carefully  feel  for  the  most  distended 
coil  within  reach,  and  bring  this  up  into  the  incision.  This  must  now 
be  opened  and  an  artificial  anus  formed  as  described  below  at  p.  224. 

It  may  happen  that  this  plan  will  result  in  the  opening  of  a  coil 
above  the  obstruction,  or  that  the  obstructed  portion  of  intestine  is 
already  gangrenous,  and  in  either  of  these  cases  the  result  must  be 
fatal.  On  the  other  hand,  it  may  be  urged  that  in  these  extreme  cases, 
further  interference  would  be  almost  certainly  fatal,  even  though  the 
obstruction  were  relieved,  and,  moreover,  that  the  most  distended  coils 
of  intestine  usually  rise  to  the  surface  and  are  situated  close  to  the 
umbilicus ;  and,  finally,  that  a  few  lives  have  certainly  been  saved  by 
this  means. 

Having  spoken  of  the  operation  generalh".  I  shall  next  refer  to  a  few 
practical  points  connected  with  the  chief  causes  of  obstruction  indivi- 
dually. 

I.  Strangulation  by  Bands  and  through  Apertures.* 

A.  Bands.  I.  Adventitious  Feritoiueal  Bii.nds. — Perhaps  there  has 
been  a  history  of  peritonitis,  starting  possibly  from  the  cfecum,  the 
uterus  and  appendages,  or  a  mesenteric  gland.  These  bands  are  usually 
attached  by  one  end  to  the  mesentery.  2.  Oonental  Bands. — Here  some 
part  of  the  lower  end  of  the  omentum  has  become  adherent  to  the  brim 
of  the  pelvis,  a  hernial  sac,  the  uterine  appendages,  or  the  caecum, 
3.  MeckeVs  Dirertiaditm.'f — This  is  usually  met  with  in  young  subjects. 
Tubular  or  cord-like,  it  will  be  found  attached  at  one  end  to  the  ileum, 
within  three  feet  of  the  caecum,  at  the  other  near  the  umbilicus,  or  to 
the  mesentery  or  intestine.  Under  this  arch  small  intestine  is  very 
liable  to  slip.  In  other  cases  one  end  is  free,  and  ensnares  or  knots  up 
a  loop  of  intestine.  4.  Some  Noi'mal  Structure  ahnormally  attached,  e.g., 
the  Fallopian  Tiibe  or  the  Appemliv.X 

*  Sir  F.  Treves  (^Intesf.  Obxtruct.,  p.  13;  Diet.  ofSurff.,  vol.  ii.  p.  802)  groups  these 

together  from  the  similarity  of  their  obstruction  and  their  close  resemblance  to  stran- 
gulated hernia. 

f  A  most  interesting  and  fully  reported  case  successfulh'  treated  by  laparotomy  was 
published  in  the  Lancet,  March  9,  1889,  by  my  old  friend  E.  J.  Pye-Smith,  of  Shetfield. 
Two  others  successfully  treated  in  the  same  way  by  Mr.  Glutton  (^Clin.  Soc.  Trans., 
vol.  xvii.  p.  186)  and  Mr.  McGill  (^Brit  Med.  Joiirn.,  Jan.  14,  1888)  'wiU  well  repay 
reference. 

t  One  classification  of  bands  useful  to  the  operator  is  into  those  easily  found  and 
those  which  are  inaccessible. 


l8o  OPERATIONS  OX  THE  ABDOMEN. 

In  most  cases  bands,  when  found,  are  not  difficult  to  deal  with.  If 
they  do  not  give  Avay  to  the  finger  as  attempts  are  made  to  hook  them  up, 
they  should  be  divided  between  two  ligatures  of  silk.  Occasionally 
transfixion  is  required.  When  one  band  has  been  discovered,  the 
possibility  of  a  second,  attached  to  the  pelvic  brim,  must  always  be 
remembered.  In  Gibson's  list  of  cases  there  are  i86  of  obstruction  b}^ 
bands,  and  in  no  less  than  thirty-three  of  these  there  was  a  record  of 
more  than  one  band  being  present,  and  it  is  probable  that  the  proportion 
is  even  higher  than  this. 

Two  other  points  connected  with  bands  must  be  remembered :  one, 
that  if  they  are  vascular  both  ends  should  be  secured ;  the  other,  that 
on  the  division  of  the  band  the  piece  of  intestine  which  has  been  released 
may  be  found  to  be  gangrenous  or  even  perforated,  and  allowing  its  con- 
tents to  escape  into  the  peritoneeal  sac.  The  intestine  must  then  be 
brought  outside  and  drained,  and  the  peritoneal  sac  cleansed  if  possible 
(p.  215). 

Every  band  should  be  resected  as  closel}*  to  its  attached  points  as  is 
safe,  to  prevent  any  recurrence  of  the  trouble.  In  the  case  of  a  diver- 
ticular band  which  is  tubular,  the  contiguous  peritonseal  contents  being- 
all  shut  off"  with,  sponges  or  tampons,  the  diverticulum  and  the  intestine 
into  which  it  opens  are  emptied  bj"  pressure.  Then  the  diverticulum, 
being  lightly  clamped,  is  divided,  an  inch  and  a  half  or  two  inches  from 
the  intestine,  the  mucous  coat  is  disinfected  with  pure  carbolic  acid  and 
tied  with  silk  or  sutured  with  a  few  silk  sutures,  while  a  second  row, 
which  takes  up  and  inverts  the  muscular  and  serous  coats,  gives  further 
security. 

B.  Apertures  and  Slits. — These  may  be  congenital  or  traumatic. 
The  two  following  cases  are  good  instances,  and  show  in  sharp  contrast 
the  difficulties  which  may  be  met  with : 

In  Mr.  Howard  Marsh's  case  (^Brit.  Med.  Jonr/i. .June  2,  1888)  a  loop,  probably  in  the 
middle  of  the  jejunum,  had  slipped  through  a  hole  in  the  mesentery.  The  edge  of  this 
opening  was  so  yielding  that  Mr.  Marsh  could  readily  stretch  it  with  his  finger-nail 
sufficiently  to  allow  the  loop  to  be  drawn  out.  The  patient  made  a  good  recovery, 
though  in  much  danger  for  a  while  from  the  paralysed  condition  of  the  intestine. 

In  Sir  F.  Treves's  case  (^Oper.  Snrg.,  vol.  ii.  p.  3S9)  the  intestine  was  strangulated  in  the 
foramen  of  Winslow.  Here  the  surgeon  not  only  could  not  reduce  the  gut  by  operation 
during  life,  but  at  the  necropsy  he  could  not  bring  about  reduction  until  the  hepatic 
artery,  portal  vein,  and  bile  duct  were  severed. 

In  the  case  of  either  bands  or  apertures  it  is  the  lower  part  of  the 
ileum  which  is  usually  strangulated. 

II.  Intussusception. — From  its  frequency,  especially  in  early  life,  its 
fatality  in  infants,  and  the  fact  that  its  treatment  is  less  unsatisfactory 
because  its  diagnosis*  is  easier  than  other  forms  of  obstruction,  this 
deserves  cai-feful  notice.  Of  the  varieties — the  enteric,  the  colic,  the 
ileo-colic,  and  the  ileo-ceecal — the  frequency  of  the  last  is  well  known. 
It  is  to  this  variety,  especially  in  children,  that  the  following  remarks 
mainly  apply. 

The  treatment  depends  upon  the  duration  of  symptoms.     In   quite 

*  Two  points  must  always  be  remembered  in  the  diagnosis  of  intussusception : 
(i)  that  in  cases  which  are  not  acute  there  may  be  very  few  symptoms  for  some  time  ; 
(2)  the  rectum  must  always  be  examined,  and  any  intussusception  which  may  be  met 
with  not  mistaken  for  a  prolapsus. 


ACUTE  INTESTINAL  OBSTRUCTION.  l8l 

early  cases,  reduction  will  generally  be  possible  with  comparatively  little 
ibrce,  and  may  be  brought  about  satisfactorily  by  injection  or  intlation. 
Ver}'  soon,  however,  the  engorgement  of  the  intussnsceptum  and  the 
included  mesenter}^,  or  the  adhesion  of  the  entering  and  returning  layers 
as  the  result  of  peritonitis,  renders  reduction  much  more  difficult  or 
impossible.  In  such  cases  distension  of  the  colon  will  either  fail  alto- 
gether, or  will  produce  only  partial  reduction  with  subsequent  speedy 
relapse.  The  following  figures  from  Gibson's  list  {loc.  supra  cit.)  will 
serve  to  emphasise  this  important  point:  94  per  cent,  of  the  cases 
treated  within  the  first  twenty-four  hours  were  reducible  on  abdominal 
section,  whereas  only  61  per  cent,  of  those  treated  on  the  third  day  were 
reducible.  The  proportion  reducible  by  distension  would  necessarily 
have  been  less  than  the  above  in  each  case. 

The  following  results  of  distension  will  also  serve  to  emphasise  the 
importance  of  attempting  reduction  by  distension  of  the  bowel  in  early 
cases  only,  and,  moreover,  show  how  fruitless  the  practice  of  repeating 
distension  is  likel}^  to  be  after  it  has  once  been  tried  and  has  failed. 
Mr.  Eve  collected  twenty-four  cases  from  the  records  of  the  London 
Hospital  in  which  distension  was  tried.  Of  these  six  died  without  further 
treatment,  and  the  remaining  eighteen  required  operation.  Mr.  Barker 
(Clin:  Soc.  Trans.,  vol.  xxxi.)  tried  distension  in  eight  cases,  in  all  of 
which  it  failed  ;  and  in  a  collection  of  cases  by  Wiggins,  distension  failed 
in  75  per  cent,  of  seventy-two  cases  in  which  it  was  tried. 

^iforeover,  the  following  objections  to  distension  must  not  be  lost  sight 
of : — (i)  The  danger  of  sudden  collapse  or  rupture  of  the  bowel ;  (2)  the 
loss  of  valuable  time,  rendering  the  result  of  a  laparotomy  less  likely  to 
be  successful ;  (3)  it  will  be  of  no  use  in  enteric  intussusceptions  (which 
form  22  per  cent,  of  all  cases),  and  probably  of  no  use  in  ileo-colic  intus- 
susceptions (which  form  12  per  cent.),  so  that  in  34  per  cent.,  or  in  one 
case  in  every  three,  it  is  practically  certain  to  fail. 

If  the  case  is  seen,  therefore,  within  twenty-four  hours  of  the  onset 
of  symptoms,  distension  of  the  bowel  may  be  tried.  Either  water  or 
air  may  be  used  for  this  purpose ;  of  these  the  latter  is  to  be  preferred, 
as  being  less  dangerous. 

A  little  A.C.E.  mixture  being  given,  the  lower  limbs  being  somewhat 
raised,  the  nozzle  of  a  Lund"s  inflator,  or  a  full-sized  catheter,  or  a  rectal 
tube,  attached  by  tubing  to  a  bellows  and  well  coated  with  vaseline,  is 
carefully  passed  into  the  bowel.  The  nates  being  securely  pressed 
round  the  tube,  air  is  steadily  pumped  into  the  colon,  while  the  surgeon 
keeps  one  hand  on  the  abdomen,  not  only  to  prevent  over-distension, 
but  also  to  watch  for  any  receding  of  the  tumour  towards  the  ceecal 
region. 

With  regard  to  the  force  used,  Dr.  Goodhart  {Dis.  of  Cltihl.,  p.  125), 
remarks :  "  Replacement  of  the  bowel  can  usually  only  be  effected  by 
considerable  distension  of  the  »vhole  colon,  and  distension  of  the  colon 
sometimes  requires  a  good  deal  of  rather  forcible  pumping  to  complete 
it."  This  is  especially  the  case  with  regard  to  the  last  few  quantities  of 
air  sent  in.  Dr.  Taj^or's  advice  here  will  minimise  the  risk  of  rupture 
of  the  bowel :  "  The  risk  can  be  reduced  to  a  minimum  by  injecting, 
carefully  and  slowly,  successive  small  quantities,  and  by  gently  kneading 
the  abdomen  so  as  to  facilitate  the  passage  of  air  upwards,  and  thus 
prevent  the  sudden  over-distension  of  short  lengths  of  the  colon." 


I82 


OPERATIONS  ON  THE  ABDOMEN. 


If  inflation  fails,  and  in  all  cases  seen  later  than  twenty-four  hours 
after  the  onset  of  symptoms,  abdominal  section  should  be  at  once  pro- 
ceeded with. 

Operation. — The  child  being  under  the  influence  of  the  A.C.E. 
mixture,  the  parts  being  cleansed,  and  any  urine  drawn  off,  an  incision 
is  made,  usually  in  the  middle  line,*  sufficient  to  admit  of  the  easy 
introduction  of  two  or  three  fingers.  Before  opening  the  peritonasal 
sac  all  bleeding  should  be  entirely  arrested.  The  intussuscepted  mass 
is  now  found,  and,  if  possible,  hooked  out  into  the  wound.  But  more 
often  this  is  impossible,  and  the  reduction  must  be  effected  in  situ. 

Prof.  Senn  advises  {loc.  infra  cit.,  p.   128)  that:    "The  oedema  and 

Fig.  44. 


Diagram  of  au  intussusception  in  vertical  section. 
M,  Mesentery,  a,  Artery,  v,  Vein,  d.v,  Dilated  vein,  i.m,  Inflamed  mesentery. 
OR,  Orifice  of  bowel  at  apex  of  iutussusceptum  with  thickened  mucous  membrane 
around.  A,  Line  drawn  througli  usual  seat  of  adhesions.  B,  Line  for  resection  of 
intussusceptum.  x,  x,  To  mark  the  vertical  incision  through  which  resection  is  per- 
formed.    (Greig  Smith.) 

inflammatory  swelling  should  be  removed  before  any  attempts  at  reduc- 
tion are  made.  This  can  be  readily  accomplished  by  steady  and  unin- 
terrupted manual  compression  of  the  invaginated  portion."  My  own 
experience  here  is  disappointing. 

The  following  points  must  now  be  carefully  attended  to.  If  the 
intussusception  cannot  be  brought  outside,  two  fingers  of  each  hand 
should  be  introduced,  and  an  attempt  made  (i)  to  draw  out  the  intus- 
susception Avhile  the  point  of  entrance  is  held  steadily.     As  a  rule,  this 

*  As  speed  is  very  important  in  these  cases  in  children,  the  surgeon  should  give  him- 
self enough  room  by  beginning  above  the  umbilicus.  The  intussusception  usually  lies 
deeply  and  is  difficult  to  get  at. 


ACUTE  INTESTINAL  OBSTRUCTION.  183 

is  only  partially  successful.  (2)  The  lower  end  of  the  invaginated  part 
being  found,  the  ensheathing  layer  should  be  pulled  down,  while  the 
ensheathed  part  is  pushed  up.  When  the  end  of  the  intussusception  has 
reached  the  rectum,  help  may  be  given  by  an  assistant  with  a  bougie ; 
but  it  will  usuall}'  be  found  that  pushing  or  backing-out  the  contained 
bowel  by  gently  squeezing  movements  between  the  finger  and  thumb, 
these  being  gradually  shifted  along  the  gut,  will  prove  successful,  when, 
by  no  force  that  is  justifiable,  could  any  part  be  drawn  out. 

Whichever  method  is  found  to  answer  best  must  be  persevered  with 
until  every  atom  of  the  mass  is  reduced,  this  being  often  known  by  the 
appearance  of  the  vermiform  aj)pendix. 

If,  when  the  reduction  is  complete,  any  tears  are  noticed  in  the  peri- 
tonjeal  coat,  these  must  be  sewn  up  with  a  fine  continuous  silk  suture, 
and  a  little  iodoform  rubbed  in. 

Every  care  should  be  taken  throughout  the  operation  to  prevent 
chilling,  both  of  the  child's  body  and  limbs,  and  especially  of  any  intes- 
tine which  may  have  to  be  withdrawn. 

As  in  all  abdominal  sections,  this  operation  should  be  concluded  as 
speedih'  as  may  be. 

When  the  intussusception  cannot  be  reduced,  all  attempts  at 
traction  and  kneading  only  causing  tears  in  the  peritonasal  coat,  the  fol- 
lowing courses  are  open  according  to  the  condition  of  the  patient,  &c. : — 
(l)  If  the  intussusception  is  gangrenous  but  small  in  amount,  it  should 
be  resected.  For  the  union  of  the  divided  ends  Murphy's  button  has  the 
great  advantage  of  saving  time,  and  is  thus  well  adapted  to  acute  and 
subacute  cases  in  children,  which  form  the  majorit}^  of  the  cases.  What- 
ever method  is  used  some  difficulty  must  be  expected  in  effecting  exact 
union  in  the  common  variety,  the  ileo-caecal,  owing  to  the  difference  of 
the  lumen  in  the  two  parts  of  the  bowel ;  where  this  difficulty  is  very 
marked,  the  best  plan  will  be  to  close  both  ends  by  a  double  row  of 
sutures,  continuous  and  Lembert's,  and  then  to  make  a  lateral  anas- 
tomosis {q.v.)  hj  means  of  Murphy's  button,  Robson's  bobbin,  &c.  (2)  If 
the  invagination  is  irreducible  but  not  gangrenous,  it  may  be  left,  and 
the  continuity  of  the  canal  restored  hj  short-circuiting  the  small  and 
large  intestine  above  and  below  the  invagination  by  Murphy's  button  or 
some  other  means.  (3)  Where  the  patient's  condition  is  good,  as  in 
chronic  cases,  an  ii*reducible  intussusception  is  best  treated  by  an  ope- 
I'ation  based  b}^  Mr.  Jessett  (Surg.  Dis.  of  Stomach  and  Intesfines,  p.  140) 
on  what  is  known  as  spontaneous  cure.  It  was  three  times  performed 
successfully  on  dogs.  An  invagination  having  been  made  artificially, 
and  found  a  week  later  firmly  adherent,  it  was  thus  removed.  A  longi- 
tudinal opening  was  made  into  the  intestine  over  the  root  of  the  intus- 
susception on  the  side  farthest  from  the  mesentery,  about  an  inch  and 
a  half  long,  of  sufficient  length  to  allow  the  invaginated  part  to  be 
drawn  out  with  vulsellum  forceps.  The  root  of  the  invaginated  part 
having  been  pulled  out  through  the  above  opening,  was  cut  through  close 
to  its  origin,  any  vessel  \A'hich  required  it  being  tied.  Then  the  divided 
coats  where  the  intussusception  had  been  cut  away  were  united  with  a  lew 
points  of  suture,  the  lumen  of  the  bowel  being  left  open.  The  stump 
was  then  returned  into  the  intestine,  and  the  incision  in  this  closed  by 
quilt  sutures.  Greig  Smith  (Abclom.  Sicnj.,  p.  6/6)  recommended  this 
method  of  treatment,  but  modified  the  operation  in  cases  of  extensive 


1 84 


OPERATIONS  ON  THE  ABDOMEN. 


invagination,  in  that,  as  will  be  seen  by  reference  to  Figs.  45  and  46, 
he  removed  onl}^  the  apex  of  the  intussnsceptnni,  this  being  the  most 
swollen  part,  and  therefore  the  chief  obstacle  to  reduction.  The  rest 
was  then  gently  reduced.  Although  reduction  will  be  rendered  possible 
in  some  cases  by  removal  of  the  apex  of  the  intussusceptum,  in 
others  the  adhesion  of  the  layers  at  the  neck  of  the  intussusception,  to 
one  another,  will  make  reduction  impossible.  In  such  cases,  a  more 
complete  resection  of  the  intussusceptum  will  be  necessary.  Other  and 
less  desirable  methods  which  may  be  thrust  on  the  surgeon,  owing 
to  the  circumstances  under  which  he  operates,  are :  (4)  Resection  and 
formation  of   an  artificial  anus.*     (5)  Formation  of  an  artificial  anus 


Fig.  45. 


Fig.  46. 


Diagram  showing  removal  of  apex  of  intussusceptum 

through  an  incision  in  the  intussuscipiens. 

I,  Entering  bowel.      2,  Neck  of  intussuscipiens.     3, 

Incision   in   intussuscipiens.     4,   Cut  edges   united  by 

sutures.     5,  Apex  of  intussusceptum  excised.     (Greig 

Smith.) 


Operation  of  resec- 
tion of  intussuscep- 
tum completed. 
(Greig  Smith.) 


without  resection.  Finally,  in  those  rare  cases  of  invagination  of  the 
colon  into  the  rectum  the  intussusception  may  be  drawn  down  and 
removed  by  the  operations  of  Mikulicz,  or  Mr.  Barker  iia  this  countrv. 
The  latter  surgeon's  cases  will  be  found  in  the  Med.-Ckir.  Trans.,  1887, 
vol.  Ixx.  p.  335,  and  Brit.  Med.  Journ.,  vol.  ii.  1892,  p.  1226.  In  both 
cases  a  malignant  growth  was  at  the  root  of  the  invagination,  and  in 
each  operation  steps  were  facilitated  by  the  ease  with  which  the  growth, 
after  dilatation  of  the  anus,  could  be  pulled  outside.  Two  rows  of 
sutures  were  made  to  encircle  the  bowel,  and  to  unite  the  two  layers  of 
the  intussusception  firmly  together  well  above  the  new^  growth.     As  the 


*  Prof.  Senn  quotes  a  case  of  Wassiljew's  (^Ccntr.f.  C'hlr.,  188S,  No.  12),  in  which  an 
operation  was  performed  to  close  the  artificial  anus  six  months  later.  It  was  ultimately 
successful. 


ACUTE  INTESTINAL  OBSTRUCTION.  185 

sutures  were  passed,  care  was  taken  that  no  small  intestines  protruded. 
Both  cases  recovered,  and  the  first  was  alive  four  or  five  years  after  the 
operation. 

III.  Volvulus. — The  intestine  here  is  usually  either  twisted  on  its 
mesenteric  axis,  or  bent  at  an  anefle.  The  first  is  the  acuter  condition, 
owing  to  the  strangulation  of  vessels.  It  is  usually  met  with  in  the 
sigmoid  flexure,  when  this  has  a  long  meso-colon,  especially  in  adults 
who  have  been  subject  to  constipation  (Treves).  The  distension  may  be 
enormous,  the  sigmoid  appearing  to  occupy  the  whole  abdomen. 
Ulceration  leading  to  fatal  peritonitis  may  set  in,  either  in  the  sigmoid, 
the  colon,  or  the  ciecum. 

A  free  incision  will  be  required  here,  so  as  to  enable  the  surgeon 
to  get  at  the  root  of  the  volvulus.  The  volvulus  may  present  at  once  as 
a  hugely  distended  coil ;  it  may  be  felt  as  a  localised  collection  of  intes- 
tine ;  if  twisted,  the  twist  may  feel  like  a  band,  and  a  band  may  actually 
complicate  the  case  as  when  a  vermiform  appendix  is  coiled  round  the 
root  of  the  twist  of  the  volvulus  (Brit.  Med.  Journ.,  vol.  ii.  1892.  p.  170). 
If  attempts  at  reduction  fail,  the  volvulus  should  be  drained  by  tapping 
or  incising  the  summit  of  the  loop,  this  being  brought  outside  the  peri- 
tongeal  cavity.  Fresh  attempts  at  reduction  are  then  made,  and  if  they 
succeed,  and  if  there  is  no  tendency  for  the  volvulus  to  reform,  the 
opening  is  closed,  and  the  intestine  thoroughly  cleansed  and  returned. 
If  reduction  is  impossible,  an  artificial  anus  must  be  made  immediately 
above  the  volvulus,  this  having  been  first  completely  emptied  and 
closed. 

In  a  ver}'  few  cases  where  the  volvulus  is  persistent  or  recurrent,  and, 
at  the  same  time,  of  small  extent,  it  may  be  resected  if  the  patient's  con- 
dition admits  of  it.     But  volvuli  of  small  extent  can  usually  be  reduced. 

The  following  points  are  noteworthy  in  the  diagnosis  and  treatment 
of  volvulus.  It  is  not  uncommon  for  this  form  of  obstruction  to  follow 
an  injury,*  some  loop  of  bowel  distended  with  fasces,  and  with  a  long 
mesentery  probably  becoming  suddenlj^  displaced  and  unable  to  recover 
itself.  Again,  this  form  of  obstruction  has  been  noticed,  whether  as 
a  mere  coincidence  or  not,  in  many  cases  in  the  insane.  Finally,  at  the 
time  of  treatment.  Sir  F.  Treves's  warning  (Oper.  Surg.,  vol.  ii.  p.  390) 
must  always  be  remembered:  "'The  reduction  of  a  volviilus  does  not 
usually  remove  the  anatomical  condition  that  led  to  it."  The  truth 
of  this  is  shown  by  their  tendency  to  recur. 

Thus  the  late  Mr.  Greig  Smith  (^Abdom.  Surf/.,  p.  450)  described  a  case  of  volvulus  of 
the  small  intestine  which  recurred  a  week  after  it  had  been  untwisted  by  abdominal 
section.  Enterotomy  was  then  performed,  and  the  patient  for  some  time  wore  a 
catheter  in  the  opening  to  allow  of  the  passage  of  flatus  into  a  bottle  which  he  carried 
in  his  pocket.  After  some  time  the  distended  bowel  had  so  contracted  that  the  use  of 
the  catheter  could  be  dispensed  with.  Dr.  Finney  reports  (Johns  Hopliins  Ho.^p.  Bull., 
March  1893)  a  case  of  volvulus  which  involved  the  whole  colon  between  the  ileo-csecal 
valve  and  the  sigmoid ;  it  was  rectified  by  operation,  and  recurred  nearly  three  years 
later.     A  second  recovery  followed. 


*  See  cases  mentioned  by  Mr.  Turner,  Dr.  F.  Hawkins,  and  Mr.  Stavely  (Lancet, 
vol.  ii.  1892,  p.  995)  ;  a  case  successfully  operated  on  by  Mr.  Silcock  (Clin.  Soc.  Trans., 
vol.  xxviii.  p.  180).  References  arc  made  in  the  latter  paper  to  eight  successful 
cases  operated  on  abroad. 


1 86  OPERATIONS  ON  THE  ABDOMEN. 

Prof.  Senn  has  advocated  shortening  the  meso-colon  to  meet  this 
tendency  to  recurrence.  Fixation  of  the  colon  by  two  or  three  points  of 
suture  might  be  tried  as  less  risky,  if  access  is  not  prevented  by  disten- 
sion of  the  small  intestines.  In  any  case,  great  care  will  be  needed 
by  such  patients  in  their  diet  and  to  ensure  efficient  action  of  their 
bowels. 

IV.  Gallstones,  Intestinal  Calculi,  &c.  —  Gallstones,  the  most 
common  of  these,  present  cases  very  favourable  for  operation  if  taken  in 
time,  owing  to  the  simplicity  of  the  cause  of  obstruction,  and  the  facility 
with  which  it  may  be  usually  dealt  with.  Operation  has  been  here  too 
often  deferred,  owing  to  the  fact  that  these  patients,  usually  advanced  in 
life,  and  stout,  are  not  well  suited  to  operation  from  a  general  point  of 
view,  and  because  it  has  been  strongly  insisted  upon  by  some  that  if 
pain  and  spasm  can  only  be  removed,  the  local  cause  of  the  obstruction 
will  pass  on.  This  I  believe  to  be  a  mistake.  Sir  F.  Treves  (Intest. 
Obstruct.,  p.  335)  states  that  of  twenty  cases  in  which  gallstones  "pro- 
duced definite  and  severe  symptoms  of  obstruction,"  six  patients  reco- 
vered by  the  spontaneous  passage  of  the  stone,  and  fourteen  died 
unrelieved.  It  is  to  be  hoped  that  the  successful  cases  which  have  been 
])ublished,  one  as  long  ago  as  1887  (Lancet,  Dec.  3),  by  Mr.  T.  Smith, 
Mr.  Glutton  (Clin.  Soc.  Trails.,  vol.  xxi.  1888,  p.  99),  and  more  lately  by 
Mr.  A.  Lane  (ibid.  ii.  1894,  p.  382),  and  Mr.  Eve  (Cliii.  Soc.  Trans., 
vol.  XXV.  1895,  P-  91))*  i^^^y  ^^^^1'  good  fruit.  In  some  cases,  in  addition 
to  the  age,  stoutness,  and  habits  of  the  patient,  the  history  of  previous 
inflammation  in  the  neighbourhood  of  the  gall-bladder  may  help  the 
diagnosis ;  in  four  cases,  certainly,  the  calculus  has  been  felt — the 
abdomen  being  undistended — before  operation.  But  in  the  majority  it 
is  probable  that  here,  as  elsewhere,  operation  alone  will  demonstrate 
the  cause  of  the  obstruction. 

The  following  courses  may  be  adopted  :  ( i )  To  try  and  pass  on  the 
stone  through  the  ileo-cascal  valve  into  the  large  intestine.  Mr.  Glutton 
(Clin.  iSoc.  Trans.,  vol.  xxi.  p.  99)  succeeded  in  doing  this,  the  stone 
being  situated  eight  inches  above  the  valve.  But  usually  the  stone 
is  too   firmly  fixed. 

Mr.  Glutton's  case  is  a  very  instructive  one.  The  patient,  a  woman  aged  70,  was 
operated  upon  within  twenty-four  hours  of  the  beginning  of  the  attack.  Fifteen 
months  before  she  had  passed  a  large  facetted  biliary  calculus,  and  after  her  recovery 
from  this  had  had  a  swelling  in  the  region  of  the  gall-bladder.  This  disappeared  with 
the  onset  of  the  obstruction.  A  median  incision  four  inches  long  having  been  made, 
the  stone  was  readily  felt,  and  though  it  tightly  iitted  the  lumen  of  the  intestine 
it  could  be  forced  along.  As  owing  to  the  early  date  at  which  the  operation  was 
performed,  there  was  no  marked  difference  between  the  intestine  above  and  below  the 
obstruction,  the  site  of  the  ileo-csecal  valve  was  determined  by  making  out  the  caecum 
and  the  appendix.  There  was  not  much  difficulty  in  urging  the  calculus  in  the  right 
direction,  but  as  soon  as  the  valve  was  reached  some  considerable  force  was  required  to 
make  it  pass  through.  This  most  successful  case  strongly  supports  Mr.  Glutton's  advo- 
cacy of  an  early  operation,  before  the  stone  has  become  so  immovable  as  to  require 
opening  of  the  intestine. 

Dr.  Maclagan  Qihid.,  p.  97)  draws  attention  to  an  important  point.      If  other  stones 


*  In  this  paper  some  thirty  cases  which  have  been  treated  by  abdominal  section  are 
given  and  the  result  considered. 


ACUTE  INTESTINAL  OBSTRUCTION.  187 

exist  in  the  gaU-bladdcr  or  ducts,  another  may  descend  before  the  wound  is  healed,  and, 
forcing  its  way  through  the  recent  incision,  cause  fatal  peritonitis. 

(2)  If  the  stone  does  not  feel  very  hard  a  cautious  attempt  may  be 
made  to  critsh  it  between  flat-bladed  forceps,  guarded  with  drainage 
tube.  Such  a  course  can  only  be  adopted  when  the  intestine  imme- 
diately adjacent  to  the  stone  is  healthy.  (3)  The  same  precaution  must 
be  taken  if  Mr.  Tait's  suggestion  of  breaking  up  the  stone  with  a  needle 
is  resorted  to.  If  used,  the  needle  must  puncture  obliquely,  an  inch  and 
a  half  from  the  stone.  (4)  If  the  stone  cannot  be  pushed  onwards,  and 
if  it  is  too  hard  to  be  broken  up,  it  must  be  removed.  The  loop  being 
drawn  well  outside  the  peritonasal  cavity,  an  incision  must  be  made  in 
the  intestine  opposite  to  the  mesenteric  border,  the  calculus  removed, 
care  being  taken  that  its  long  axis  corresponds  with  that  of  the  wound 
and  that  the  edges  of  this  are  not  bruised.  The  wound  is  then  closed 
most  carefully  with  Lembert's  or  Halsted's  sutures,  silk  being  used. 
Whichever  of  the  last  three  methods  is  resorted  to,  the  stone  must, 
if  possible,  first  be  pushed  into  an  absolutely  healthy  part  of  the  intes- 
tine, if  that  surrounding  it  is  inflamed  or  thinned.  (5)  If  the  condition 
of  the  intestine  is  suspicious,  or  if,  on  opening  it  for  the  removal  of  the 
stone,  the  mucous  coat  is  ulcerated,  one  of  the  three  following  courses 
must  be  followed,  according  to  the  .condition  of  the  patient  and  the 
resources  of  the  operator,  viz. :  (a)  Resection.  (/S)  Formation  of  an 
artificial  anus.  (7)  Where  the  operator  is  doubtful  if  his  sutures  will 
hold,  but  desires  to  give  this  method  a  chance,  he  will  suture  the  wound 
of  extraction  and  then  bring  this  outside,  packed  around  with  iodoform 
gauze  for  twenty-four  or  forty-eight  hours,  or  leave  it  just  within  the 
abdominal  wound,  anchored  here  by  a  catgut  stitch,  and  shut  off  from 
the  rest  of  the  peritona^al  sac  by  tampons  of  iodoform  gauze  (wrung  out 
of  I  in  20  carbolic-acid  lotion),  the  ends  of  which  are  brought  out 
through  the  parietal  incision. 

V.  Thrombosis  of  the  Mesenteric  Vessels  or  of  Abdominal  Aorta. 
— Mention  must  be  made  of  the  above  conditions,  as  it  is  clear,  from  the 
cases  published,  that,  though  rare,  they  may  simulate  acute  intestinal 
obstruction  very  closely.  The  explanation  appears  to  be  that  a  loop  of 
intestine,  deprived  of  its  blood-supply  by  an  embolus,  will,  functionally, 
be  as  completely  paralysed  as  if  it  had  been  strangled.  Instructive 
cases  of  this  kind  M'ill  be  found  published  by  Mr.  M'Carthy  (Lancet, 
vol.  i.  1890,  p.  646)  and  Dr.  Munro,  of  Middlesbrough  (ibid.,  vol.  i. 
1894,  p.  147). 

Dr  Munro  quotes  from  Gerhardt  and  Kussmaul  the  following  diagnostic  points  of 
these  cases  :  (i)  A  source  of  origin  for  the  embolus  ;  (2)  profuse  hiemorrhage  from  the 
bowels  ;  (3)  severe  colic-like  pains  in  the  abdomen  ;  (4)  rapid  reduction  of  tempera- 
ture ;  (5)  demonstration  of  an  embolus  in  some  of  the  other  arteries  ;  (6)  palpation  of 
infarcts  in  the  mesenteries.  In  Dr.  Munro's  case,  one  of  these,  situated  in  the  meso- 
sigmoid,  could  be  felt,  before  operation,  in  the  left  iliac  fossa.  To  these  points  might 
be  added  advanced  age  and  no  evidence  of  malignant  disease.  The  mischief  is  usually 
too  extensive  to  admit  of  surgical  interference.  If  it  be  limited  to  the  small  intestine, 
several  branches  are  usually  plugged. 

The  recorded  cases  have  almost  invariably  ended  fatally.  In  one 
case,  however,  the  portions  of  bowel  and  mesentery  involved  were 
removed  with  success. 

Before  closing  the  account  of  the  surgical  treatment  of  acute  intestinal 


1 88  OPERATIONS  ON  THE  ABDOMEN. 

obstruction,  I  must  allude  to  Prof.  Senn's*  advice  to  try  insufflation 
with  hydrogen,  in  order  to  find  the  seat  of  obstruction. 

Prof.  Senn,  finding  that  distension  of  the  entire  gastro-intestinal  canal  (for.  owing 
to  distension  of  tlie  csecum.  tlie  ileo-caecal  valve  is  paralysed)  in  animals  was  never 
followed  by  any  ill  effects,  has  advised  this  (i)  in  reduction  of  intussusception,  (2)  in 
locating  the  obstruction  during  a  laparotomy,  (3)  in  detecting  the  site  of  gunshot  or 
other  perforations  of  the  intestine.  The  gas  is  collected  in  a  four-gallon  rubber 
balloon,  and  the  inflation  made  by  compressing  the  balloon.  A  manometer  or  mercury 
gauge  connects,  by  rubber  tubing,  the  rectal  tube  on  one  side  and  the  balloon  on  tlie 
other. 

This  method,  though  extremely  ingenious,  is  likely  to  have  but  a  limited  application. 
In  the  reduction  of  intussusceptions  the  use  of  ordinary  air  is  much  more  handy,  and 
has  been  abundantly  successful.  In  the  detection  of  perforations,  especially  those  by 
gunshot,  the  test  has  certainly  answered,  but  the  following  risks  are  connected  with  its 
use.  It  will  demonstrate  perforations,  but  nothing  else,  and  may  lead  the  operator,  if 
he  trusts  to  it,  to  overlook  many  other  lesions  which  may  be  as  dangerous  as  perfora- 
tions themselves.  Many  conditions — e.ff.,  impacted  fseces,  prolapse  of  mucous  mem- 
brane, and  recent  adhesions — may  interfere  with  its  efficacy  (Morton).  Though  aseptic 
when  introduced,  the  gas  can  hardly  be  so  after  passing  through  many  feet  of  intestine. 
It  may  break  down  most  vital  adhesions.  It  may  increase,  by  the  distension  it  causes, 
the  danger  of  the  anaesthetic,  and  is,  of  course,  only  available  in  cases  where  there  is 
little,  if  any.  distension. 

APPENDICITIS.! 

Before  discussing  the  question  of  surgical  interference  here,  it  will  be 
well  to  make  plain  what  we  mean  \\'hen  speaking  later  of  the  varieties 
of  this  disease.     These  are  : 

i.  Catarrhal  and  Early  Interstitial  Apjjendicitis. — Here  the  inflamma- 
tion is  limited  to  the  mucous  membrane  and  the  other  coats  of  the 
appendix,  but  goes  no  farther  (if  the  attacks  be  slight)  than  at  the  most 
a  little  plastic  peritonitis  and  a  few  slight  adhesions. 

ii.  Appendicitis  with  a  Localised  Ahscess. 

iii.  Acide  Perforatinrj  and  Ganrjreiious  Appendicitis. — Of  these  two, 
the  first  may  at  any  time  lead  to  a  general  peritonitis ;  the  second,  if 
left,  always  does  so. 

iv.  L'elapsing  or  Recurrent  Appendicitis. 

Question  of  Operative  Interference  in  Acute 
Appendicitis. 

When  to  Operate  and  When  to  Wait.     Two  Camps  of  Opinion. 

One  of  us  has  already  said,  in  a  lecture  elsewhere  (W.  H.  A. 
Jacobson,  Polyclinic,  Dec.  1900),  much  of  what  follows  concerning 
the  present  state  of  opinion  on  this  subject. 

"  (a)  Ad.vocates  of  Waiting  and  Watcldny. 
'•  Those  who  follow  on  these  lines  rely  on  the  fact  that  the  majority  of 

*  Zoc.  svpra  cit.,  p.  53;  and  Journ.  Amer.  Med.  Assoc,  June  1888:  "Rectal  Insuffla- 
tion of  Hydrogen  Gas  an  Infallible  Test  in  the  Diagnosis  of  Visceral  Injury  of  the 
Gastro-intestiual  Canal  in  Penetrating  AVouuds  of  the  Abdomen." 

f  I  use  this  term,  ctymologically  unsatisfactory,  because  it  is  convenient  and  based 
on  correct  pathology. 


APPENDICITIS.  189 

cases  of  appendicitis  recover  under  medical  treatment.  In  other  words, 
they  represent  that  the  dangei'oiis  forms  in  which  slong-hing  or  gangrene 
or  perforation  of  the  appendix  with  suppurative  peritonitis,  pylephle- 
bitis, &c.,  follow,  ai-e  but  few.  Dr.  Hawkins,  quite  one  of  the  highest 
authorities  on  the  subject,  puts  the  death-rate  of  appendicitis  at  14  per 
cent.,  and  hopes  it  may  be  reduced  to  12  per  cent. 

"  With  all  respect  to  Dr.  Hawkins,  I,  mj'self,  look  upon  the  above 
estimate  of  14  per  cent,  as  too  low,  when  hospital  cases  are  considered. 
It  is  interesting  to  note  that  Dr.  MacDougall.  in  his  address  at  Carlisle 
in  1896,  quoting  from  returns  made  from  the  Edinburgh  Royal  Infir- 
mary for  the  three  years  1893,  1894,  and  1895,  found  that  the  death- 
rate  of  acute  appendicitis  was  25  per  cent.,  and  that  the  returns  of  two 
London  Hospitals — St.  Bartholomew's.  1893  to  1895,  and  St.  Thomas's, 
1892  to  1894 — gave  a  death-rate  of  nearly  20  per  cent.,  and  it  is 
doubtful  if  these  returns  included  all  the  cases  admitted  of  puralent 
peritonitis.  .   .  . 

"  The  advocates  of  waiting  and  watching  further  maintain  that  in  the 
indiscriminating  removal  of  appendices  which  they  say  has  been  goinp- 
on  in  America,  we  have  had  an  abuse  of  surgery  similar  to  that  whicli 
characterised,  some  years  ago,  the  operation  of  oophorectoni}". 

"  (b)  The  Advocates  of  Operation  ai  Once,  or  at  the  End  of  Thirtij-six 
or  Forti/-eir/ht  Hours. 

"  Let  us  consider  how  this  school,  to  which,  I  confess,  I  have  felt 
myself  di-awn  increasingly  during  the  last  few  years,  would  answer  the 
objections  to  early  operation  which  I  have  just  mentioned.  And  I  will 
take  the  last  first,  viz.,  the  criticism  that  this  opei-ation  of  early  removal 
of  the  appendix  has  been  abused,  and  the  comparison  between  it  and  the 
similar  abuse  with  which  most  of  us  are  familiar  as  to  oophorectomy. 

"'  There  is  an  old  saying  that  '  Abusiis  non  tollit  usum.'  A  pendulum 
of  opinion  which  sways  strongly  first  in  one  direction,  then  in  another, 
needs  watching.  And  in  my  opinion  there  is  a  danger  that  in  being 
influenced  by  the  needless  operations  which  have  no  doubt  been  done  in 
America  and  elsewhere,  we  shall  lose  sight  of  the  very  sound  and 
splendid  work  done  by  the  best  surgeons  of  that  country.  I  shall  allude 
to  this  more  in  detail  shortly.  I  will  only  add  that  in  this  countrv 
hasty  and  needless  operating  will  certainly  not  be  the  rule  of  treatment. 
l3ut  there  is  a  risk  that  in  priding  ourselves  on  this,  we  err  on  the  other 
side.  I  am  certain  that  the  results  of  the  best  American  surgeons  are 
far  superior  to  anything  in  this  country,  and  are  but  little  known 
amongst  us. 

"  With  regard  to  the  comj^arison  between  removal  of  the  appendix 
and  the  ovary,  I  scarcely  think  this  holds  good.  A  diseased  ovary  mav 
cripple,  but  it  very  rarely  kills  ;  it  is  not  a  vestigial  structure  ;  though 
unsound,  it  is  not  necessarily  functionless.  An  appendix  has  not,  like  the 
ovary,  peculiar  importance  not  only  to  its  owner,  but  also  perhaps  to 
others,  an  importance  quite  sui  fjeneris.  The  advocates  of  early  operation 
would  answer  to  the  conservative  school :  '  You  sanction,  nay.  perhaps 
you  urge  operation  as  soon  as  evidence  of  gangrene,  perforation,  suppu- 
rative peritonitis,  or  local  abscess  is  certain.  But  by  the  time  the 
evidence  is  sufficient  for  you  to  call  in  surgerv  it  is  often  too  late ;  you 


I90  OPERATIONS  ON  THE  ABDOMEN. 

admit  that  it  is  usually  impossible  to  diagnose  such  conditions  as 
gangrene  and  perforation  till  the  disaster  is  announced  by  evidence  which 
is  unmistakable,  but  which  announces  a  condition  in  which  surgical 
interference  is  too  often  useless.' 

"The  advocates  of  early  operation  claim  that  by  operating  early,  and 
thus  making  sure  that  infection  has  not  extended  beyond  the  appendix, 
the  surgical  death-rate  would  be  much  below  the  medical  one,  "which  we 
have  seen  to  be  put  by  one  of  the  best  authorities  at  14  per  cent.  Thus 
Dr.  Morriss  holds  that  the  death-rate  should  not  exceed  4  or  5  per  cent, 
when  cases  of  gangrene,  perforation,  and  suppurative  peritonitis  are 
operated  on,  and  goes  so  far  as  to  say  that  a  surgical  death-rate  of  2  per 
cent,  in  cases  operated  on  early  '  would  be  illegitimate.' 

"  Let  us  examine  this  claim  that  the  medical  death-rate  will  be  much 
lo^vered  by  early  surgical  interference.  It  will  be  seen  to  stand  or  fall 
very  largely  upon  the  meaning  of  the  word  '  early.'  The  question  at 
once  arises,  '  How  many  cases  are  really  seen  within  the  first  twenty-four 
or  thirty-six  hours  ? '  Certainly,  I  think  but  few  in  hospital  practice. 
Here  the  patient  very  often  goes  on  working  for  days  after  he  has  had 
warnings  of  pain,  and  even  sometimes  with  a  lump  in  his  right  iliac 
fossa.  We  must  face  the  fact  that  it  will  be  difficult  to  determine  whether, 
with  this  word  '  early '  before  us,  we  really  are  dealing  with  the  first 
twenty-four  or  thirty-six  hours.  A  patient,  from  carelessness  or  inac- 
curacy, or  a  desire  to  make  the  best  of  his  case,  from  a  dread  of  operation, 
may  misrepresent  his  symptoms  as  just  beginning.  In  reality  this  man 
had  had,  for  a  day  or  two,  pain  or  other  evidence  that  a  catarrhal  con- 
dition has  been  established,  and  thus  the  appendix  epithelium  has  had 
time  to  become  shed,  and  an  infection-atrium  has  had  the  opportunity^  of 
forming  before  a  medical  man  is  asked  to  see  the  patient.  Then,  when 
the  latter  is  called  in,  the  pulse,  temperature,  pain,  tenderness,  and  so 
forth  betoken  not  the  commencement  of  an  attack  as  the  patient  repre- 
sents, but  a  stage  in  which  an  actual  abrasion  is  present,  perhaps  even 
that  the  peritonaeum  is  becoming  infected. 

"  Having  mentioned  this  caution,  we  will  suppose,  for  the  sake  of 
argument,  that  all  cases  are  seen  within  a  really  early  stage,  viz., 
twenty-four  hours.  Is  it  certain  that  early  operation  at  this  stage  will 
be  largely  successful  ?  Let  us  examine  the  ground  on  which  we  stand. 
If  we  accept  Dr.  Hawkins's  mortality  of  appendicitis  treated  medically 
as  one  of  14  per  cent,  from  gangrene,  perforation  of  the  appendix,  and 
suppurative  peritonitis,  in  order  to  ensure  a  surgical  mortality  of  4  or  2 
per  cent. — though  Dr.  Morriss  is  inclined  to  look  upon  even  the  latter  as 
'  illegitimate  ' — it  is  clear  that  we  must  operate  successfulli/  on  ninety-six 
or  ninety-eight  cases  of  acute  appendicitis  in  the  early  stage.  This  is  a 
statement  which  there  is  no  gainsaying,  and  it  is  one  which  at  once 
makes  a  mind  capable  of  weighing  evidence  veiy  thoughtful.  When  one 
considers  the  conditions  under  which  this  early  operation  may  have  to 
be  done,  in  a  febrile  patient  with  an  infected,  septic  organ  to  be  removed, 
with  intestines  very  likely  distended,  and  many  other  conditions  present 
the  very  reverse  of  those  which  make  an  operation  during  the  quiescent 
stage  so  successful,  it  is  difficult  to  say  how  far  the  medical  mortality  of 
14  per  cent.,  or,  perhaps  more  correctly,  of  20  per  cent.,  will  be  reduced, 
even  if  the  surgery  be  always  that  of  skilled  hands.  That  it  will  be 
reduced  by  habitual  earlier  operation,  and  in  the  lifetime  of  some  of  us, 


APPENDICITIS.  191 

I  am  certain  ;  but  I  doubt  if  it  will  be  broug-ht  below  8  per  cent.,  when 
all  the  conditions  and  the  different  personal  equations  of  the  operators 
are  weighed. 

"  But,  here,  it  will  be  only  just  to  examine  some  of  the  results  gained 
by  the  best  of  those  American  surgeons  who  advocate  early  operation  in 
every  case.     These  results  are  not  sufficiently  known  in  this  countr}'. 

"  I  will  take  only  two  of  the  more  recent  ones,  viz.,  those  of  Dr. 
Mynter,  of  Xiagara,  and  Dr.  Morriss,  of  Xew  York.  Dr,  Mynter 
(Appendicitis,  p.  172),  whose  book  emphatically  bears  the  stamp  of  a 
candid  and  judicious  worker,  writing  in  1 897,  had  had  thirteen  cases, 
all  of  which  had  more  or  less  total  gangrene  but  yet  without  perforation. 
They  all  recovered  by  prompt  operation  and  extirpation  of  the  appendix. 
Two  cases  were  operated  on  during  the  first  day.  five  on  the  second  day, 
two  on  the  third  day,  three  on  the  fourth  day,  and  one  on  the  seventh 
day.  'These  cases,'  he  goes  on  to  say,  '  are  most  interesting,  as  giving 
conclusive  evidence  of  the  importance  of  operating  before  perforation 
has  occurred.  No  one  can  doubt  that  perforation  with  profuse  perito- 
nitis would  shortly  have  occurred,  and  that  they  all  would  have  died 
under  any  other  than  surgical  treatment.' 

"  Dr.  IMynter  operated  on  another  group  of  twenty  cases,  all  of  which 
had  gangrene  with  perforation  of  the  appendix,  and  commencing  or 
diffuse  peritonitis.  Five  of  these  recovered,  while  fifteen  died — thirteen 
of  diffuse  peritonitis,  one  of  gangrene  of  the  caecum,  and  one  of  suppu- 
rating pvlephlebitis  after  the  peritonitis  had  disappeared.  The  five  who 
recovered  were  operated  on,  in  two  cases  on  the  first  day,  in  two  cases 
on  the  second  day.  and  in  one  case  on  the  third  day.  Of  the  fifteen  who 
died,  one  was  operated  on  during  the  second  day,  two  on  the  third  day, 
five  on  the  fourth  day,  two  on  the  fifth  day,  four  on  the  sixth  day,  and 
one  on  the  seventh  day. 

"Dr.  Mynter  adds:  'Comment  seems  unnecessary;  all  died  if 
operated  on  later  than  the  third  day.' 

"  Dr.  Morriss's  cases  (Lectures  on  AppendAcitis,  Xew  York,  1895)  ^"^^ 
somewhat  less  carefully  tabulated,  but  are  most  instructive. 

"  Of  ninety-one  cases  of  acute  appendicitis  operated  on  early,  injifti/- 
nine  in  which  only  the  immediate  vicinity  of  the  ajypendix  ivas  infected, 
although  many  of  these  cases  involved,  extensive  operative  icorTi,  there  was 
no  death  in  this  series  of  fifty-nine  cases. 

"  In  six  cases  of  intense  general  septic  peritonitis,  with  the  whole 
abdominal  cavity  bathed  in  pus,  only  one  patient  died. 

"  In  three  cases  with  intense  general  septic  peritonitis,  not  marked  by 
the  presence  of  pus,  only  one  died. 

"  In  twenty-three  cases  of  the  walled-off  abscess  form  of  appendicitis, 
the  most  varied  complications  were  present.  Five  only  of  these  died,  but 
one  of  these  deaths  was  from  acute  suppurative  nephritis,  a  second  fi'om 
'  intestinal  obstruction  dvie  to  adhesions  which  could  not  be  separated  at 
the  time  of  operation  on  account  of  the  patient's  condition,'  and  a  third, 
already  weak  from  several  months'  septicaemia  due  to  an  abscess  over- 
looked before  Dr.  Morriss  saw  the  case,  died  of  a  continuance  of  the 
septicaemia. 

"  This  death-rate  of  seven  in  ninety-one  cases  testifies  in  no  uncertain 
terms  to  the  admirable  care  and  skill  which  must  have  been  exercised  to 
attain  such  a  result. 


192  OPERATIONS  ON  THE  ABDOMEN. 

"  Dr.  Morriss  is  quite  justified,  after  such  success,  in  writing:  '  I  feel 
that  the  death-rate  in  lOO  such  cases  as  the  list  contains  should  not  be 
more  than  4  or  5  per  cent.,  notwithstanding  the  fact  that  many  of  the 
cases  were  in  a  condition  which  seemed  to  prohibit  interference.' 

"  It  seems  to  me  that  even  if  this  surgical  death-rate  of  4  or  5  per 
cent,  were  doubled,  viz.,  8  or  10  per  cent.,  it  would  give  a  better  result 
than  the  medical  one  of  14  or  20  per  cent.,  and  our  duty  would  be 
clear. 

"  But  the  following  cautions  must  be  borne  in  mind : 

"  First,  that  we  have  here  the  results  of  especial  experience  of  those 
Mdio  have  had  opportunities  of  acquiring  especial  skill.  Dr.  Mynter 
strikes  a  very  important  note  when  he  emphasises  the  point  that 
wherever  the  home  surroundino-s  are  unfavourable,  the  well-reo-ulated 
operating-room  of  a  home  or  hospital  is  a  sine  qua  non. 

"  Secondl}^  it  is  never  to  be  forgotten  that  these  operations  are 
alwaj^s  serious,  often  very  difficult,  and  that  they  require  good  experi- 
ence, efficient  assistance,  and  efficient  antiseptic  precautions. 

"  Thirdly,  in  estimating  the  surgical  death-rate,  which  I  do  not  myself 
expect  to  be  less  than  6  or  8  per  cent.,  when  all  the  conditions  under 
which  this  operation  will  be  performed  are  taken  into  account,  we  must 
remember  that  in  certain  cases  of  appendicitis  beginning  very  acutely 
the  operation,  however  early,  will  not  save  life.  I  refer  to  cases  where  a 
general  peritonitis  sets  in  early,  possibly  within  the  first  few  hours  of 
the  case  coming  under  notice.  The  explanation  of  these  cases  probably 
is  that  in  some  it  is  not  really  a  first  attack.  The  history  given  is 
unreliable,  the  appendix  is  already  a  damaged  one,  and  either  gangrene 
or  a  perforation  of  its  unhealthy  structures  sets  in  quickly,  with  the 
resiilt  of  a  rapid  general  peritonitis.  In  others,  the  explanation  is  that 
the  bacillary  activity  is,  from  the  first,  acute,  the  resisting  power  of  the 
patient's  tissues  verj^  poor,  or  that  some  minute  point  in  the  anatomy  of 
the  appendix,  as  the  gaps  between  the  fibres  of  the  muscular  roots  [vide 
siqrra).  facilitates  rapid  transit  of  the  septic  process.  No  one  can  tell 
how  often  the  lives  of  our  patients  hang  on  such  minute  points. 

"  There  is  another  of  the  points  of  dispute  between  the  two  camps  to 
which  I  would  ask  3-our  attention.  The  advocates  of  early  operation 
maintain  that  many  of  the  cures  which  are  secured  by  medical  treatment 
— we  will  call  them  80  or  85  per  cent.— are  not  permanent  and  complete 
cures  when  followed  up ;  bixt  that  permanent  mischief  is  left  behind, 
sometimes  slight,  sometimes  severe  and  dangerous  ;  and  that  patients 
would  be  saved  from  the  great  annoj^ance  and  suffering  of  recurrent 
attacks  and  much  waste  of  time  if  the  appendix  were  removed  in  the 
first  attack.  The  following  is  an  interesting  instance  of  how  incomplete 
may  be  the  cure  of  a  case  treated  on  medical  lines,  and  of  the  thread  on 
which  such  a  patient's  life  ma}^  be  hanging: 

"  A  gentleman,  aged  23.  was  sent  to  me  in  July,  1896.  by  Dr.  Goodhart  with  the  fol- 
lowing history  : — In  1895  ^^^  had  had  a  severe  attack  of  appendicitis,  in  which  the  tem- 
perature was  for  some  days  between  102°  or  103°.  Under  medical  treatment  he  made 
an  apparently  perfect  recovery.  In  June  1896,  while  bowling  for  an  eleven  of  the 
Zingari  at  Manchester,  as  he  shot  up  to  the  crease  he  suddenlj-  felt  an  acute  pain  and 
<lropped  to  the  ground.  He  was  carried  to  an  hotel  in  a  state  of  collapse,  and  when  the 
mischief  had  abated  came  into  my  hands,  as  I  have  said.  There  was  the  characteristic 
thickened  knotty  lump  and  tenderness  at  one  small  spot  in  the  right  iliac  fossa.     The 


..APPENDICITIS. 


193 


appendix,  when  removed,  showed  a  good  deal  of  thickening  in  its  distal  half,  but,  save 
for  the  adhesion  of  one  single  tag  of  omentum  at  one  spot,  it  struck  me  as  being 
strangely  free  from  adhesions,  considering  the  severity  of  the  two  attacks.  The  patient 
made  a  good  recovery,  and  is  now  growing  and  exporting  that  excellent  dry  sherrv. 
'  Pando,'  at  Xeres.  I  happened,  after  the  operation,  to  pass  a  probe  down  the  lumen  of 
the  appendix,  when,  to  my  surprise,  the  blunt  end  pa,ssed,  without  the  slightest  force, 
through  the  walls  at  a  spot  exactly  where  the  tag  of  omentum  was  adherent.  Here  the 
end  of  the  probe  could  be  seen  just  covered  by  a  filmy  layer  of  peritonjeum  only.  The 
chief  events  of  the  illness  and  the  very  narrow  escape  of  the  patient  stood  out  very 
clearly.  In  the  first  severe  attack,  with  a  temperature  of  103°,  the  appendix  had 
suffered  very  severely ;  no  walling-off  life-saving  adhesions  had  formed,  save  the  one, 
single  and  omental.  As  the  patient  was  bowling  his  very  best,  the  uplifted  arm  and 
rotation  of  the  whole  trunk  upon  one  leg  brought,  by  means  of  the  latissimus  dorsi. 
pectoralis  major,  and  external  oblique — all  continuous  with  each  other  and  with  the 
muscles  of  the  lower  limb  at  Poupart's  ligament — a  violent  strain  upon  the  abdominal 
wall,  and  so  upon  the  omental  tag,  causing  a  stretching  here,  and  perhaps  a  minute  tear, 
and  thus  the  agonising  pain  and  collapse  which  heralded  the  onset  of  the  second 
attack. 

"  There  is  one  other  of  the  points  of  dispute  between  the  two  schools 
to  which,  as  a  surgeon,  1  must  allude.  By  the  opponents  of  routine 
early  operation  it  has  been  objected  that  such  a  course  would  be  followed 
by  a  large  number  of  ventral  hernige.  There  is,  no  doubt,  truth  in  this, 
for  the  incision  will,  in  many  cases,  have  to  be  free  in  ordei-  to  find  the 
appendix  and  to  enable  the  surgeon  to  get  his  field  of  operation 
thoroughly  isolated  with  gauze  tampons ;  secondly,  drainage  will  often 
be  required. 

"  But  a  ventral  hernia  must  weigh  lightly  against  a  saved  life.  To  put 
this  matter  succinctly,  it  will  be  better  for  such  a  patient  to  be  fitted 
with  an  abdominal  belt  than  to  be  measured  for  his  coffin." 

Such  is,  I  think,  a  fair  expression  of  the  two  camps  of  opinion  on  this 
subject. 

For  my  own  part,  then,  I  consider  that  an}-  physician  is  justified  in 
asking  a  surgeon  who  is  skilled  in  abdominal  surgeiy  and  who  has  the 
necessary  aids,  &c.,  to  remove  the  appendix  as  soon  as  the  diagnosis 
is  made.  Again,  I  hold  very  strongh^  that  every  physician  is  nc-t 
onh-  justified  in  asking,  but  bound  to  ask,  a  sm-geon  skilled  in  this 
branch  of  surgery  to  interfere  at  the  earliest  possible  moment  in  certain 
cases — viz.,  where  the  evidence  of  appendicitis  is  from  the  first  severe 
and  progressive.  Of  the  evidence,  the  most  valuable  points  are  marked 
pain,  tenderness,  and  vomiting.  Next  in  value  to  these  I  should  place 
the  temperature  and  pulse.  These  may  be  fallacious,*  the  temperature 
sometimes  falling  and  perforation  taking  place  a  few  hours  later. 
Another  guide  to  which  I  attach  much  importance  is  the  early  look  of 
grave  illness  or  anything  approaching  to  the  pinching  of  the  "facies 
Hippocratica."  Two  other  points  of  evidence  which  are  of  great  import- 
ance, but  which,  it  is  to  be  hoped,  the  surgeon  will  be  allowed  to  tiy  and 

*  In  Mr.  G.  Barling's  words  {Brit.  Med.  Journ.,  vol.  i,  1895,  p.  1135)  :  "  The  tempera- 
ture is  an  uncertain  guide,  and  one  only  to  be  relied  upon  when  confirmed  by  other 
phenomena.     If  it  present  the  paradox  of  a  falling  temperature  with  a  quickening 

pulse  the  improvement  in  the  former  would  be  a  fallacious  guide The  great 

point  in  recognising  these  cases  is  not  to  regard  any  one  point  as  essential  to  tliagnosis. 
It  is  desirable  to  dwell  not  too  much  on  the  absence  of  one  particular  feature,  as  upon 
the  intensity  of  those  which  are  present." 

VOL.  II.  I  q 


194  OPERATIONS  ON  THE  ABDOMEN. 

forestall,  are  a  tendency  for  the  abdominal  wall  to  become  fixed,  and  a 
tympanites  spreading  from  the  right  iliac  fossa. 

I  should  like  to  call  attention  to  one  other  point  to  which  I  attach 
great  impoi-tance,  and  that  is,  the  position  of  the  most  marked 
tenderness,  resistance,  and  swelling,  if  present.  The  more  internal 
to  McBurney's  point  this  evidence  is  found,  the  greater  the  risk  that 
perforation  will  light  up  a  general  peritonitis  instead  of  one  limited 
to  the  iliac  fossa.  We  have  learnt  much  of  late  years,  from  American 
writers  {e.g.,  Bryant  and  Fowler),  of  the  importance  of  remembering  the 
position  of  the  appendix  {Ann.  of  Surg.,  vol.  i.  1893,  p.  164;  vol.  i. 
1894,  p.  12).  It  is  clear  that  when  the  appendix  is  directed  internally, 
not  only  is  the  risk  of  general  suppurative  peritonitis  greater  if  the 
appendix  perforate,  but  if  a  localised  abscess  form  it  is  more  likely 
to  communicate  with  the  pelvis,  and  perhaps  open  into  the  rectum  or 
vagina  ;  if  adhesions  form  about  it  there  is  a  greater  risk  of  much 
more  important  structures  being  involved — viz.,  the  iliac  vessels,  ureter, 
bladder,  &c. — than  if  the  appendix  be  directed  downwards,  when  it 
may  be  only  adherent  to  Poupart's  ligament.  Many  other  instances  of 
the  practical  bearing  of  anatomy  upon  the  different  positions  of  the 
appendix  will  suggest  themselves. 

I  will  now  allude  more  particularl}'  to  one  sign  wdiich  I  have  only 
mentioned  above,  viz.,  swelling.  Although  some  degree  of  swelling  is 
usually  present  in  the  right  iliac  region,  it  cannot  be  too  strongly 
insisted  upon  that  in  cases  of  "  fulminating"  appendicitis  there  may  be 
no  swelling  from  first  to  last.*  In  a  very  few  cases  swelling  is  absent 
from  the  right  iliac  fossa,  but  present  elsewhere  owing  to  the  appendix 
being  misplaced.  Thus,  a  very  few  cases  of  left-sided  appendicitis  have 
been  recorded.  Dr.  Fowler  {Ann.  of  Surg.,  1894,  vol.  i.  p.  160)  publishes 
a  case  in  which  there  was  marked  tenderness  in  the  direction  of  the  gall- 
bladder. No  appendix  could  be  found  in  the  usual  place,  as  it  lay 
behind  the  liver.     Again,  rectal  examination  may  reveal  a  pelvic  swelling. 

It  will  be  seen  that  the  above  opinion  of  mine,  that  any  physician  is 
justified  in  asking  a  surgeon  skilled  in  this  branch  of  surgery  to  operate 
in  cases  of  appendicitis  in  the  earliest  stages,  and  that  he  is  bound 
to  do  so  where  certain  evidence  just  given  points  to  probable  rapid 
perforation,  is  not  the  same  thing  as  sanctioning  the  removal  of  the 
appendix  as  a  routine  jji'actice  by  anj'one  who  thinks  himself  competent 
to  do  so.  Considering  the  increasing  tendency  at  the  present  day  for 
surgery  to  be  taken  out  of  the  hands  of  properly  qualified  surgeons,  men 
with  a  hond-fide  and  lifelong  hospital  training,  and  for  it  to  pass  into 
the  hands  of  those  who  have  no  such  ripe  experience,  no  such  operative 
training,  and  who  are  occupied  with  other  work  and  other  claims  not 
always  running  on  smooth  lines  with  aseptic  surgery — considering  this 
and  its  effects,  any  such  wholesale  and  routine  removal  of  the  appendix 
would  be  attended  with  disastrous  consequences. 

*  Some  cases  mentioned  by  Dr.  Tyson,  of  Folkestone,  at  one  of  the  discussions 
on  this  subject  at  the  Clinical  Society  (^Lancet,  vol.  i.  1892,  p.  424),  form  good 
instances  of  the  truth  of  this.  In  three  cases  in  which,  after  mild  symptoms  had 
lasted  for  three  days,  there  was  sudden  collapse  and  death,  there  had  been  sickness 
and  tenderness,  but  no  swelling.  Operation  was  performed  in  one  case  unsuccess- 
fully. In  all  three  suppurative  peritonitis  following  perforation  of  the  appendix  was 
found. 


APPENDICITIS.  195 

Operative  Interference   in   Acute  Appendicitis  with 

Abscess. — A  few  years  ago  there  was  a  tendency  to  wait  until  the 
abscess  was  thought  to  be  safe — i.e.,  till  it  was  walled  in  by  adhe- 
sions, and  generally  till  it  showed  signs  of  being  adherent  to  the 
abdominal  wall, — the  reason  given  being  that,  if  opened  before,  the 
risk  was  great  that  the  peritonasal  sac  would  become  infected.  On 
the  other  hand,  it  is  clear  that  in  waiting  we  run  serious  risks,  for : 
(a)  the  abscess  may  rupture  and  burst  into  the  peritonseal  sac,  espe- 
cially if  the  patient  is  restless  ;  (h)  the  pus  will  burrow,  e.g.,  into  the 
pelvis,  opening  into  the  rectum  or  bladder,  downwards  under  Poupart's 
ligament,  or  backwards  and  upwards  to  the  loin,  all  these  directions 
being  influenced  by  the  position  in  which  the  appendix  was  lying  before 
the  attack. 

These  risks  being  increasingly  recognised,  there  is  a  greater  ten- 
dency to  try  and  find  the  pus  early.  The  following  is  the  best 
evidence  as  to  the  early  existence  of  pus : — Persistence  and  increase 
of  the  symptoms,  both  local  and  general,  after  thirty-six  to  forty-eight 
hours ;  marked  local  resistance  and  tenderness ;  *  a  persistent  and 
usually  progressive  swelling-f  Later  obvious  points  are  the  time- 
honoured  ones  of  the  hectic  character  of  the  temperature,  oedema, 
fluctuation,  and  redness. 

The  question  of  resorting  to  the  exploring  needle  must  now  be  alluded 
to.  This  has  been  advocated  by  some  American  surgeons.  Sir  F.  Treves 
(loe.  supra  cit.)  strongly  condemns  it,  as  :  (i)  it  is  not  free  from  risk,  as 
the  needle  may  be  thrust  into  important  parts  ;  (2)  it  may  tap  an 
appendix  distended  with  foetid  mucus,  and,  allo^^'ing  some  of  this  to 
escape,  bring  about  a  suppuration  which  was  by  no  means  inevitable ; 
(3)  an  incision  is  more  reliable. 

Operation. — The  skin  having  been  shaved  and  cleansed,  an  incision 
three  to  four  inches  long  is  made,  if  there  be  no  swelling,|  much  as  for 
ligature  of  the  external  iliac,  crossing  McBurney's  line  and  lying  about 
one  inch  and  a  half  above  Poupart's  ligament.  The  inner  extremity 
should  not  open  the  deep  epigastric  vessels.  The  peritonaeum  having 
been  reached,  this  is  most  carefulh'  opened, §  all  bleeding  having  been 
previously  arrested.  The  appearances  will  now  differ  accordingly  as  the 
surgeon  is  operating  to  relieve  the  patient  of  an  abscess  or  of  an  appendix 
v-liich  is  on  the  point  of  rupture.  The  second  condition  will  be  taken  first. 
There  may  be  an '  entire  absence  of  adhesions,  the  appendix  being 
swollen,  thickened,  and  rigid ;  or  thickened  and  contracted  at  one  spot, 

*  This  may  be  masked  by  unwisely  given  opium. 

t  The  swelling  may  be  very  slight  or  difficult  to  detect  from  the  rigidity  of  the  abdo- 
minal walls  and  the  flinching  of  the  patient  unless  an  anaesthetic  be  given. 

X  This  incision  is  very  greatly  to  be  preferred  to  one  in  the  linea  semilunaris, 
and  a  fortiori  to  one  in  the  linea  alba,  because  it  gives  very  much  more  direct 
access  to  the  parts  concerned.  If  one  in  the  linea  semilunaris  be  made  it  will  be 
found  that  the  outer  edge  of  the  wound  often  requires  to  be  strenuously  drawn 
aside  to  enable  the  surgeon  to  get  at  the  appendix.  This  use  of  the  retractor  may 
lead  to  bruising  of  the  wound.  Again,  if  a  surgeon  working  in  the  linea  semi- 
lunaris needs,  as  is  often  the  case,  to  come  low  down,  the  deep  epigastric  vessels 
must  be  divided. 

^^  If  adherent  intestine  is  present  the  incision  must  be  extended  so  as  to  open  a 
normal  part  of  the  peritonseal  cavity. 


ig6  OPERATIONS  OX  THE  ABDOMEX. 

and  dilated  beyond,  the  "cystic''*  form  of  appendix  of  some  writers. 
There  may  be  gangrenous  patches  at  tip  or  base.f  or  the  appendix,  itself 
gangrenous,  may  be  embedded  in  gangrenous  adhesions. 

The  treatment  of  the  appendix  must  vary  ^\'ith  its  condition  and  the 
state  of  the  patient.  It  should  alwaj^s  be  removed  if  possible.  The 
wound  being  well  opened  out  and  the  adjacent  peritonseal  contents 
having  been  shut  off  with  tampons  of  iodoform  gauze,  the  appendix  is 
separated,  if  possible,  from  any  adhesions  present,  and  dealt  with 
according  to  one  of  the  following  methods.  If  gangrenous  it  should  be 
cut  away  as  near  to  the  cfecuni  as  is  safe,  and,  if  its  coats  here  will  not 
bear  ligature  and  sutures,  the  stump  must  be  disinfected  with  pure 
carbolic  or  nitric  acid,  and  one  end  of  a  strip  of  iodoform  gauze  wrung 
out  of  carbolic  acid  lotion  (i  to  20)  placed  in  contact  with  the  stump, 
and  the  other  brought  outside  the  abdomen,  sufficient  of  the  wound 
being  left  open  for  the  renewal  of  this.  Any  adhesions  that  are  slough}- 
or  gangrenous,  and  that  cannot  be  snipped  away,  should  be  scraped  out 
with  a  sharp  spoon,  disinfected  as  far  as  possible  in  the  same  way 
as  the  stump,  the  healthy  parts,  lips  of  the  wound,  &c.,  being  kept  away 
from  them  by  iodoform  gauze. 

When  the  appendix  is  inflamed  and  soft,  but  not  actually  gan- 
grenous, it  will  be  quite  sufficient  to  trust  to  ligature  with  medium- 
sized  sterilised  silk,  about  three-quarters  of  an  inch  from  the  ctecum. 
If  the  state  of  the  patient  or  the  softened  condition  of  the  appendix 
prevent  anything  more  being  done,  these  measures  Avill  be  found  quite 
sufficient,  if  pure  carbolic  acid  be  applied  to  the  mucous  membrane  on 
the  stump  so  as  to  disinfect  this.  If  the  appendix,  where  cut  through, 
be  healthy  or  only  thickened,  one  or  other  of  the  following  methods 
may  be  adopted. 

Mr.  Barker  (Brit.  Med.  Journ.,  vol.  i.  1895,  P-  863)  recommends  the 
following  method  of  double  ligature  as  being  simple  and  rapid.  It  is 
based  on  the  fact  that  when  the  appendix  is  much  thickened  the  mucous 
and  sub-mucous  coats  can,  after  circular  division  of  the  other  coats,  be 
drawn  out  in  an  mibroken  tube.  The  mesentery  having  been  first  trans- 
fixed, tied,  and  severed  near  the  caecum,  the  serous  and  muscular  coats 
are  divided  circularly  about  three-quarters  of  an  inch  from  the  caecum. 
The  mucous  and  sub-mucous  tube  is  now  drawn  out,  and  the  outer  coats 
having  been  stripped  back,  as  in  a  circular  amputation,  towards  the 
caecum,  the  above-mentioned  tube  is  tied  close  to  its  juncture  with  the 
caecum  with  fine  silk  and  cut  off.  It  at  once  retracts,  the  outer  tube  is 
drawn  down  over  it  and  tied  with  fine  silk  or  gut.  Another  plan, 
which  is  equally  rapid  and  satisfactory,  is  to  ligature  and  remove  the 
appendix  close  to  the  caecum,  then  to  invert  the  stump  of  the  appendix 
into  the  caecum  by  means  of  a  circular  purse-string  suture,   situated 

*  This  would  seem  a  fortiori  to  be  a  very  dangerous  condition,  for  if  the  patient 
recover  from  one  attack  with  a  cystic  condition,  the  appendix  may  give  way  at  this 
weakened  spot  during  the  next  attack, 

t  Dr.  Fowler  (^A7in.  of  Siirg.,  vol.  i.  1894,  p.  332)  had  the  great  good  fortune  to  open 
the  peritonaeal  cavity  after  the  appendix  had  perforated,  but  before  any  of  its  contents 
had  escaped.  "  The  appendix,  absolutely  free  from  adhesions,  was  swollen  to  the  size 
of  a  little  finger,  and  perforated  in  two  places.  These  were  minute  openings,  through 
which  soft  faecal  matter  oozed  as  the  ligature  was  tightened  about  the  base  of  the 
organ  preliminary  to  its  excision."     The  patient  made  a  good  recovery. 


APPENDICITIS.  197 

about  a  quarter  of  an  inch  from  the  stump,  all  round.  This,  when 
drawn  tight  and  tied,  inverts  the  stump  of  the  appendix.  However  the 
appendix  is  removed,  when  it  is  severed,  any  escaping  contents  must  be 
received  on  gauze,  &c.  The  meso-appendix  must  always  be  looked  to, 
its  artery  properly  secured,  and  if  its  stump  can  be  drawn  over  that  of 
the  appendix,  this  will  suffice  in  place  of  any  more  elaborate  methods. 
Where  the  surgeon  is  in  doubt  about  dispensing  with  drainage  and 
closing  his  wound  entirely,  the  extent  and  severity  of  any  infective 
process,  and  the  completeness  with  which  he  has  been  able  to  disinfect 
the  deeper  parts  of  the  wound,  must  aid  in  the  decision.  The  safest 
course  in  doubtful  cases  will  be  to  leave  the  wound  partly  open,  provi- 
sional sutures  being  inserted  and  left  loose,  and  gauze  strips  employed 
(vide  su-pra). 

We  next  have  to  consider  the  different  conditions  met  loith  when,  on 
opening  the  peritonaeum,  an  abscess  is  present,  and  the  best  means  of 
dealing  with  them. 

In  those  cases — and  they  form  a  large  number — where  the  abscess 
is  made  additionally  safe  by  becoming  adherent  to  the  abdominal  wall, 
the  surgeon  will  have  a  hint  given  him  of  the  presence  of  this  condition 
by  the  oozing  and  intlammatory  matting  of  the  deeper  layers  as  he 
divides  them. 

We  vnW  suppose  a  more  difficult  case  with  no  such  tendency  of  the 
abscess  to  come  forward  through  the  abdominal  wall.  When  the  perito- 
naeum is  carefully  divided  the  structure  which  most  probably  first 
presents  itself  will  be  the  omentum  matted  down  into  the  iliac  fossa, 
perhaps  adherent  to  the  ileum,  c»cum,  or  the  neighbourhood  of  Poupart  s 
ligament.  This  being  separated  ofi",  or  secured  and  divided  in  several 
pieces,  a  mass  is  found  which  consists  of  small  intestine,  caecum,  and 
appendix.  Before  this  is  dealt  with  it  must  be  shut  off  from  the  rest 
of  the  peritonaeal  cavity  by  tampons  of  sterile  gauze.  The  operator  then 
endeavom's  to  find  any  evidence  of  a  longitudinal  band  which  will  denote 
the  «ecum  and  may  lead  to  the  appendix  itself.  If  he  find  one  or  more 
coils  of  intestine  he  gently  separates  one  from  the  other,  or  tru'ns 
the  whole  mass  upwards  carefully  from  the  fossa,  and,  while  doing  so, 
probably  gives  rise  to  an  escape  of  pus.  Perhaps  the  site  of  this  may 
be  recognised  by  a  yellowish  sloughing  spot.  The  pus  is  carefully 
mopped  away  as  fast  as  it  escapes.  If  large  in  amount  the  patient 
must  be  turned  on  to  his  right  side  to  expedite  the  flow  and  preserve 
the  peritonaeal  cavity  from  contamination. 

In  a  patient  sent  to  me  by  Dr.  Dakin,  after  tving  off  a  sheet  of  omentum,  a 
large  mass  appeared  in  ■which  I  could  not  differentiate  large  or  small  intestine.  No 
appendix  could  be  seen  or  felt.  On  gently  turning  up  the  whole  mass  a  sloughing  spot 
was  seen  below,  from  which  a  blunt-pointed  director  gave  vent  to  two  drachms  of  pus. 
Pressure  on  the  mass  was  now  made,  but  no  more  pus  escaped,  and  as  no  stercolith 
could  be  detected,  a  gauze  drain  being  inserted  down  to  the  spot,  I  closed  the  rest  of  the 
wound  by  three  layers  of  buried  sutures  (vide  infra).  A  good  recovery  followed,  and 
the  patient  has  been  able  again  to  take  briefs  at  assizes. 

The  greater  part  of  the  pus  having  escaped,  the  question  of  irrigation 
arises.  It  will  probably  be  safer  to  trust  to  drying  out  the  cavity  with 
gauze  on  holders,  and  gently  running  in  iodoform  emulsion.  Anything 
like  foi'cible  syringing  or  irrigation  is  to  be  condemned  for  fear  of 
washing  infective  particles  where  they  might  set  up  a-general  peritonitis. 


198  OPEEATIOXS  ON  THE  ABDOMEX. 

The  cavity  being  cleansed  as  thoroughly  as  possible,  the  important 
question  arises  as  to  whether  the  appendix  should  be  removed  or  not. 
The  majority  of  surgeons  consider  that  this  should  be  done  only  when 
the  appendix  lies  practically  free  within  the  abscess  cavit}^,  and  should 
not  be  attempted  where  it  enters  into  the  formation  of  the  wall  of  the 
abscess,  or  when  it  cannot  be  removed  without  separating  adhesions  on 
account  of  the  risk  of  infecting  fresh  areas  of  peritonseum  in  the  attempt, 
and  the  danger  of  prolonging  the  operation  in  these  cases.  The  remnant 
of  the  appendix,  if  left,  moreover,  will  very  probably  give  rise  to  no 
further  trouble ;  and  if,  owing  to  the  persistence  of  a  sinus  or  to  later 
attacks  of  inflammation,  its  subsequent  removal  should  become  necessary, 
this  can  be  done  under  much  more  favoitrable  conditions.  Some  sur- 
geons, on  the  other  hand,  make  a  gi'eat  point  of  removing  the  appendix 
in  every  case ;  Dr.  O'Conor,  of  Buenos  Aj-res,  for  instance,  says  {Glasgow 
Med.  Journ.,  Sept.  1899):  "I  made  it  a  rule,  some  years  ago,  never  to 
quit  the  abdomen,  when  operating  for  appendicitis,  without  taking  the 
appendix  with  me."'  Mr.  Lockwood  also  (Appendicitis,  1901)  considers 
"  that  it  is  better  for  the  patient  to  take  the  immediate  risk  of  a  deter- 
mined attempt  to  excise  the  appendix ;  but  how  far  the  attempt  should 
be  carried  must  depend  upon  the  peculiarities  of  each  case  " ;  and  he 
quotes  several  cases  where  subsequent  trouble  arose  from  leaving  an 
infected  appendix. 

Although  recurrence  and  other  troubles  do  undoubtedly  sometimes 
arise  when  the  appendix  is  left,  the  proportion  of  cases  in  which  they 
occur  is  certainly  comparatively  small — Mr.  Lockwood  puts  it  at  15  per 
cent. — and  therefore  hardly  justifies  the  greatly  increased  risk  of  the 
primary  operation  if  the  appendix  is  removed  in  every  case.  The 
appendix,  therefore,  should  be  removed,  if  this  is  possible  without 
greatly  increasing  the  risk  of  the  operation  ;  but  where  it  forms  part  of 
the  abscess  wall,  or  where  it  cannot  be  found  after  a  reasonable  search, 
the  wiser  and  safer  plan  will  be  to  leave  it.  When  found  free  in  the 
abscess  cavity,  a  transfixion  of  the  base  of  the  mesentery  with  an 
aneurysm-needle  carrying  a  loop  of  silk,  one-half  of  which  is  thrown 
round  the  appendix  and  the  other  round  the  mesentery,  the  ends  cut 
short  and  the  appendix  and  its  mesentery  amputated  just  beyond  the 
ligature,  will  probably  be  found  sufficient.  Any  projection  of  the 
mucous  coat  should  be  disinfected  (p.  196).  Whether  it  be  removed 
or  no,  if  a  perforation  be  present,  search  should  be  made  for  a  possible 
stercolith,  as  a  fistula  may  follow  for  some  time  if  one  of  these  be  left 
behind. 

In  those  cases  where  pus  has  been  present,  the  wound  should  onh^  be 
closed  in  part,  a  drainage-tube  being  inserted  and  iodoform  gauze  strips 
packed  around  it,  to  replace  the  soiled  ones  which  were  inserted  at  first. 
Provisional  sutures  should  be  passed  in  the  margin  of  the  part  not  closed, 
to  be  tightened  up  as  the  tampons  are  removed. 

The  more  reason  that  the  operator  has  to  be  doubtful  whether  he  has 
entirely  cleansed  the  abscess  cavity,  the  more  thoroughly  will  he  use 
such  antiseptics  as  glutol.  iodoform,  iodoform  emulsion,  or,  in  cases  that 
are  very  foul  or  accompanied  bv  oozing,  turpentine. 

Any  gauze  tampons  which  have  been  used  in  the  treatment  of  this  or 
the  next  variety  around  the  drainage-tube,  or  packed  amongst  loops  of 
intestine  where  these  have  been  in  contact  with  pus,  or  subjected  to 


APPENDICITIS.  199 

much  exposure  or  handling,  should  be  removed,  in  part  at  least,  on  the 
first  or  second  day.  The  object  of  the  gauze  is  to  keep  surfaces  free 
from  sources  of  sepsis,  to  immobilise  damaged  parts,  and  to  drain  by 
capillary  attraction.  But  the  longer  it  is  left  the  more  firmly  does  it 
adhere,  and  the  more  does  its  removal  cause  pain  and  bleeding.  In  some 
cases  it  will  be  judicious  to  administer  gas  when  the  bulk  of  the  gauze 
is  removed. 

Operative  Interference  in  Suppurative  Peritonitis. — 

The  perforation  here  is  due  either  to  the  acuteness  of  an  infective  process, 
to  the  pressure  of  a  stercolith,  to  both  combined,  or  to  the  rupture  of  a 
collection  of  pus.  It  is  important  to  bear  in  mind  these,  the  chief  causes, 
as  the  evidence,  both  before  and  later,  ma}^  vary  somewhat.  Thus,  sup- 
purative peritonitis  may  come  on  without  the  preliminary  warning  of  a 
swelling  (p.  194),  as  when  the  peritonitis  is  not  preceded  by  an  abscess. 
Again,  when  the  rupture  of  an  abscess  is  the  cause  of  the  peritonitis  the 
characteristic  symptoms  of  collapse  will  be  more  marked. 

The  warning*  symptoms  will  be  chiefly  those  given  at  p.  193 — viz.,  a 
case  often  severe  at  first  and  progressively  so,  severe  pain,  marked  local 
tenderness,  rigidity,  perhaps  a  swelling,  tympanites  spreading  from  the 
iliac  fossaj  early  immobility  of  the  diaphragm  and  abdomen,  obstinate 
vomiting,  earh^  and  persistently  rapid  pulse,  and  a  high  temperature.f 
Later  on,  marked  distension,  absence  of  any  peristaltic  movement,  con- 
stant vomiting  of  the  effortless  regurgitation  type,  a  pulse  increasing  in 
quickness  and  failing  in  strength,  the  drawn-up  knees,  and  the  facies 
Hippocratica — all  these  are  time-honoured  evidence  which  will  show  that 
^^•hile  surgical  interference  may  be  right,  it  will  probably  be  futile4 

Operation. — The  question  here  arises  whether  one  or  two  incisions 
are  to  be  made — viz.,  one  over  the  iliac  fossa,  and  a  median  one  as  well. 
If  there  is  well-marked  evidence  of  general  suppurative  peritonitis,  and 
if  the  patient's  condition  will  onh'  admit  of  one  incision,  probably  the 
median  will  be  best,  as  giving  more  general  access  to  the  peritonEeal  sac, 
and  perhaps  admitting  also,  by  free  retraction,  of  getting  at  the  vicinitj'' 
of  the  appendix  proper.  The  median  incision  has  also  the  advantage  of 
enabling  the  surgeon  to  see  how  far  the  peritonitis  is  general,  for 
it  must  be  remembered  that  irrigation,  especially  Avhen  carried  out 
vigorously  and  thoroughh',  may  easily  carry  infective  products  to  parts 
hitherto   uncontaminated.     But  when   the   case   admits  of   it  the  iliac 

*  Dr.  D.  B.  Lees's  cases  (^Clin.  Soc.  Trans.,  vol.  xxv.  p.  135)  show  that  a  perforation 
communicating  with  the  peritonaeal  sac,  as  long  as  this  is  shut  oif,  does  not  give  rise  to 
collapse,  and  that  the  pain,  tenderness,  &c.,  may  be  so  comparatively  slight  as  to  make 
it  appear  that  operative  interference  is  hardly  justifiable.  Yet  under  these  circum- 
stances the  delay  of  a  few  hours  may  be  fatal. 

f  Too  much  attention  is  not  to  be  paid  to  these.  In  Dr.  Fowler's  words  (Atm.  of 
Surg.,  vol.  i.  1894,  P-  I53)-  "  ^  lowering  temperature  and  a  lessening  pulse-rate  are  not 
inconsistent  with  impending  ulceration,  perforation  of  the  appendix  into  an  unpro- 
tected peritonteal  cavity,  complete  gangrene  of  the  organ,  or  rupture  of  an  appendicular 
abscess  into  the  cavity  of  the  peritonaeum." 

%  Dr.  Gerstqr  (^Ann.  of  Surg.,  vol.  ii.  1893,  P-  4^)  shows  that  in  a  few  of  these  cases  a 
stage  has  been  reached  in  which  recovery  can  only  take  place  by  letting  them  alone. 
Thus,  in  two  cases  of  his,  which  were  at  death's  door,  perforation  into  the  rectum 
occurred  without  any  of  the  shock  which  an  anaesthetic  and  operation  would  have 
caused,  and  recovery  followed.  If  a  bi-manual  examination  reveals  a  fluctuating  mass 
in  the  pelvis,  an  incision  should  be  made  here. 


2CX)  OPERATIONS  OX  TPIE  ABDOMEN. 

region  sliould  always  be  explored  first.  Ev^en  if  general,  the  peritonitis 
is  certain  to  be  severer  here,  septic  products  more  abundant,  and 
prolonged  drainage  more  required.  Moreover,  the  removal  of  a  per- 
forated or  gangrenous  appendix  will  be  much  simpler  through  an  iliac 
incision. 

The  median  incision  is  made,  the  edges  widely  retracted,  and  the 
extent  of  the  infection  made  out.  If  any  region  appears  to  be  free,  this 
should  be  shut  off  as  far  as  maj'  be  by  tampons  of  iodoform  gauze,  or  b}' 
suturing  the  omentum  to  the  cut  edge  of  the  parietal  peritonaeum  of 
that  side.  The  pus  present  is  then  got  rid  of  by  swabbing  out  with 
sterilised  gauze  or  iodoform  gauze  wrung  out  of  hot  salt  solution ; 
adherent  coils  are  separated,  most  carefully  drawn  out  and  cleansed. 
The  question  of  irrigation  will  now  arise.  When  the  pus  is  evidently 
diffused,  when  it  is  ver}^  foul,  when  the  adhesions  are  few  or  absent,  this 
may  be  employed.  Boiled  water  or  saline  solution,  at  a  temperature  of 
105°  F.,  is  preferable  to  lotions  of  mercury  perchloride  and  carbolic 
acid,  being  less  irritating.  Whether  irrigation  or  sponging  out  is 
trusted  to,  the  condition  of  the  lumbar  pouches  and  the  pelvis  must 
be  sedulously  attended  to.  The  last  named  must  be  drained  by  a  glass 
tube.* 

The  iliac  fossa  is  next  examined,  the  appendix  found,  if  possible,  and 
removed  according  to  the  directions  given  at  p.  196.  Disinfection 
(p.  215)  is  again  carried  out  by  swabbing  with  gauze,  or  irrigation,  and 
the  part  drained.  In  either  case,  if  no  special  apparatus  is  at  hand,  the 
irrigating  fluid  can  be  conducted  within  the  abdomen  by  a  sterilised 
drainage-tube,  arranged  from  a  basin,  like  an  ordinary  syphon.  Attached 
to  this  should  be  a  glass  tube,  or  a  new  large  catheter,  sterilised.  The 
elevation  of  the  tubing  will  regulate  the  force  of  the  stream.  To  aid  in 
the  removal  of  pus,  the  intestines  are  gently  moved  to  and  fro  by  the 
Angers,  and  this  may  further  be  promoted  by  gently  squeezing  and 
kneading  the  abdominal  walls.  If  there  be  time,  any  excess  of  fluid 
left  after  irrigation  is  removed  by  sponges  on  forceps.  Drainage  is 
provided  from  both  openings,  as  above  directed,  pi'ovisional  sutures 
being  inserted.  In  some  cases  it  maj^  give  an  additional  chance  to  drain 
from  one  loin  by  counter-puncture.  After  irrigation  a  glass  tube  must 
alwa3"s  be  placed  in  Douglas's  pouch  (p.  217). 

Operative  Interference  in  Relapsing  Appendicitis.— 

On  this  subject  the  profession  owes  its  lead  and  the  most  instructive  of 
its  information  to  Sir  F.  Treves,  who  first  proposed  the  removal  of  the 
appendix,  during  a  quiescent  period,  in  1877,  in  a  paper  read  before  the 
Medico-Chirurgicai  Society. f 

One  or  more  of  the  follo^^■ing  conditions,  given  by  Sir  F.  Treves,  ^\■ill  be 

*  Of  these  I  prefer  one  known  as  Chamberlen's.  It  has  one  end  rounded,  suitable  foi- 
resting  against  inflamed  iicritonaeal  surfaces,  and  the  other  drawn  out  and  narrowed, 
so  that  a  drainage-tube  for  sucking  out  is  readily  fastened  on.  But  where  concrete 
masses  of  fine  pus  ami  lymph  are  present,  the  large  open  end  of  a  Keith's  tube  is 
preferable. 

t  The  most  valuable  contributions  of  this  surgeon  are  his  Treatment  of  Tyjilditis. 
1888  and  1889;  Brit.  Med.  Journ.,  vol.  i.  1893,  p.  835,  and  vol.  i.  1895,  p.  517.  In 
America,  Dr.  H.  Myntcr,  following  on  the  lines  of  the  late  Dr.  G.  Buck,  was  one  of  the 
earliest  to  advocate  operative  steps  in  certain  cases  of  appendicitis,  especially  those 
accompanied  by  perforation  (^Buffalo  Med.  Journ..  1879,  p.  122). 


APPENDICITIS.  201 

accepted  by  all  as  j astifying  oj^eration : — (i)  The  attacks  have  been  very 
numerous.  (2)  They  are  increasing  in  frequency.  (3)  The  last  has 
been   so   severe   as  to  place  the  patient's  life  in  considerable  danger. 

(4)  The  constant  relapses  have  reduced  the  patient  to  the  condition 
of  a  chronic  invalid,  and  rendered  him  unfit  to  follow  any  occupation. 

(5)  Owing  to  the  persistence  of  certain  local  symptoms  during  the 
quiescent  period,  there  is  a  probability  that  a  collection  of  pus  exists 
in  or  about  the  appendix. 

Operation. — This  is  performed  on  the  same  lines  as  those  given  at 
p.  195.     The  details  will  vary  with  each  case. 

••  Some  of  the  cases  have  been  most  trifling.  On  the  other  hand,  in  two  instances  I 
failed  to  remove  the  appendix  after  very  persistent  attempts.  It  is  impossible  to  pre- 
dict beforehand  the  features  of  the  operation.  The  attacks  may  have  been  violent  and 
numerous,  and  the  removal  of  the  diseased  process  nevertheless  prove  to  be  a  mere  trifle. 
On  the  contrary,  some  of  the  most  diflBcult  operations  I  have  met  with  have  been  cases 
in  which  I  had  hoped,  from  the  history  of  the  attacks,  to  have  encountered  no  compli- 
cations."    (Treves.) 

The  skin  having  been  carefully  cleansed,  an  oblique  incision  is 
made  about  four  inches  long  and  crossing  McBurney's  line*  about  an 
inch  and  a  half  above  the  anterior  superior  spine.  The  aponeurosis  of 
the  external  oblique  is  divided  in  the  direction  of  its  fibres,  which  prac- 
tically corresponds  to  the  line  of  the  skin  incision,  the  small  piece  ot 
external  oblique  muscle  being  split,  also  in  the  direction  of  its  fibres. 
The  internal  oblique  and  transversalis  muscles,  which  run  in  a  direction 
almost  at  right  angles  to  that  of  the  skin  incision,  are  now  likewise  split 
in  the  direction  of  their  fibres  and  well  retracted.  By  making  the 
abdominal  incision  in  this  way,  as  described  by  McBurney  (Ann.  of  Surg., 
vol.  XX.  p.  38),  the  weakening  of  the  abdominal  wall  which  necessarily 
results  from  free  transverse  division  of  muscular  fibres  is  avoided,  and 
the  tendency  to  subsequent  ventral  hernia  thereby  greatly  diminished. 
Although  the  amount  of  room  obtained  to  work  in  by  this  method  is 
somewhat  lessened,  and  the  difficulty  of  the  operation  to  some  extent 
increased,  the  advantage  gained  is  so  distinct  that  it  should  be  adopted 
wherever  possible.  The  greatest  care  must  now  be  exei'cised,  as  the 
CEecum  may  be  adherent  to  the  peritonaeum.  If  any  difficulty  is 
experienced  the  incision  should  be  prolonged  until  it  is  certain 
that  the  peritona?al  sac  is  opened.  Any  omentum  that  is  present, 
adherent  or  thickened,  should  be  removed.  The  appendix  is  now  iden- 
tified. This  may  be  easy  or  difficult,  from  the  structure  being  embedded 
in  adhesions,  lying  under  a  c»cum  itself  fixed  by  adhesions,  or  tied  down 
in  one  of  the  loculi  which  Mr.  Lock\\'ood  has  described.  When  it  is 
found,  its  removal  may  be  rendered  difficult  or  impossible  by  the  density 
of  its  adhesions,  or  by  the  important  structures  which  these  have  impli- 
cated. Thus,  Sir  F.  Treves,  in  the  thirty-two  cases  which  he  has  published, 
has  found  it  adherent  to  the  ureter,  internal  iliac  artery,  bladder,  and 
ileum.  In  the  thirteen  cases  on  Avhich  I  have  operated,  I  was  fortu- 
nate in  only  having  to  deal  with  adhesions  to  the  ciecum,  both  to  the 
CEecum  and  one  of  Mr.  Lockwood's  loculi,  and  posterior  aspect  of 
Poupart's  ligament. 

The  following,  one  of  the  two  cases  in  which  Sir  F.  Treves  found  it 

*  This  may  have  to  be  modified  according  to  the  i:)osition  of  the  swelling. 


202  OPERATIONS  OX  THE  ABDOMEX. 

impossible  to  remove  the  aj)pendix,  gives  a  good  idea  of  the  difficulties 
which  may  he  present. 

"  For  a  considerable  time  I  was  unable  to  demonstrate  the  abdominal  cavity,  owing 
to  the  adhesions.  The  caecum  was  completely  buried  in  a  dense  mass  of  adhesions,  and 
here  was  hidden,  no  doubt,  the  appendix.  I  was  not  disposed  to  undertake  the  serious 
risk  of  opening  up  this  area,  especially  as  the  adhesions  obliterated  both  the  ureter  and 
the  iliac  veins,  structures  in  no  little  risk  of  being  wounded  in  these  operations."  The 
patient  remained  free  from  attacks  up  to  the  date  of  the  case  being  published,  six 
months  after  the  operation. 

When  the  area  in  which  the  surgeon  is  going  to  find  or  separate  the 
appendix  is  defined,  it  should  be  shut  off  with  iodoform  gauze  tampons 
or  flat  sponges.  Where  possible,  adhesions  should  be  cut  with  blunt- 
pointed  scissors ;  where  soft,  or  where  the  siirgeon  is  in  doubt  as  to 
their  nature,  they  must  be  very  carefully  torn  through  with  a  fine- 
pointed  blunt  dissector.  Where  this  separation  of  adhesions  has  opened 
the  cfecum  or  ileum,  these  must  be  carefully  closed  with  Lembert's 
sutures  (p.  229).  Where  it  is  quite  impossible  to  separate  the  appendix 
from  such  structures  as  the  bladder,  iliac  vessels,  ileum,  &c..  Sir  F.  Treves 
recommends  division  of  the  appendix  as  near  to  the  caecum  as  is  sale, 
and  then  paring  down  the  part  adherent  to  the  dangerous  viscus  until  it 
is  reduced  to  a  mere  disc.  The  actual  removal  of  the  appendix  is 
carried  out  by  one  of  the  different  methods  given  at  p.  196.  When  any 
area  has  been  unavoidably  denuded  of  its  peritonjeal  covering,  the  edges 
of  this  must  as  far  as  possible  be  drawn  together,  or  an  omental  flap 
applied.  If  this  be  impossible,  iodoform  should  be  rubbed  in  ;  and  if  the 
part  is  intestine  and  weakened,  iodoform  strips  should  be  used  to  shut 
it  off  and  drain  it,  as  directed  at  p.  198.  If  there  is  free  and  persistent 
oozing  as  the  result  of  separation  of  adhesions,  a  gauze  tampon  should 
be  packed  down  on  to  the  bleeding  surface  and  left  in  place  for  twenty- 
four  hours. 

To  minimise  as  far  as  possible  the  risk  of  hernia,  especially  in  young 
subjects  with  an  active  life  before  them,  the  wound  in  the  abdominal 
wall  should  be  carefully  sutured.  The  peritona3um,  internal  oblique  and 
transversalis,  the  ajooneurosis  of  the  external  oblique,  each  of  these  three 
layers  should  be  united  with  a  separate  row  of  buried  sutures  of  chromic 
gut  or  silk,  and  then  the  skin  with  salmon-gut.-  If  drainage  has  been 
employed,  j^ro visional  sutures  should  be  inserted. 

Complications  of  Appendicitis. — Owing  to  the  frequency  of  the  dis- 
ease and  of  operations  for  it,  it  will  be  well  to  bear  in  mind  the  chief 
complications  which  may  accompany  the  severer  cases,  and  operations 
for  their  relief.  A  mere  enumeration  must  suffice.  (l)  Intestinal 
obstruction.  This  may  be  due  ((/)  to  paralysis  of  the  intestines  from 
septic  peritonitis;  (h)  to  adhesions  about  the  appendix;  (c)  to  its 
becoming  adherent  to  some  piece  of  intestine,  mesentery,  &c.,  and  so 
incarcerating  and  strangling  a  loop  of  bowel.  (2)  Fistula.*  This  may 
be  (a)  mucous,  or  (li)  fascal.  It  may  be  due  to  incomplete  closure  of  the 
appendix,  to  the  leaving  behind  of  a  stercolith,  or  to  giving  way  of  the 
caecum  or  ileum.     (3)  Hepatic  abscess.     (4)  Empyema,  or  (5)  Purulent 

*  Treves'  Surgical  Treatment  of  'fyphlitis,  p.  45.  Mr.  Southam  has  published  (^Lancet, 
vol.  ii.  1892,  p.  835)  a  case  successfully  treated  by  short-circuiting  the  intestine.  Senn's 
plates  were  used. 


PERFORATION  OF  GASTRIC  ULCER.  203 

pericarditis.  Dr.  Fowler  shows  {loc.  supxi  cii.)  that  pus  in  the  liver  will 
tend  to  involve  the  diaphragm,  and  so  bring  about  the  last  two  conditions. 
I  should  have  thought  a  simpler  explanation  was  a  collection  burrowing 
upwards  along  the  psoas.  I  have  had  one  such  case  of  right-sided 
emi:)vema.  The  patient,  aged  53,  made  a  good,  though  very  slow,  reco- 
very, chiefly  due  to  the  devoted  attention  of  his  dresser,  Mr.  Anderson. 
(6)  Suppuration  in  the  loin  and  about  the  kidney.  (7)  Suppuration  in 
the  pelvis.  An  exceptionally  long  appendix  may  dip  into  the  pelvis  and 
bring  about  the  above.  A  case  of  this  kind  is  given  by  Fowler.  It  w^as 
successfullv  treated  by  abdominal  section.  (8)  Phlebitis  of  iliac  veins. 
Fowler  gives  a  case  in  which  the  appendicitis  being  gangrenous  brought 
about  ulceration  and  fatal  hEemorrhage.  (9)  Appendicitis  in  a  hernial 
sac.  Fowler  mentions  a  case  reported  b}-  Dr.  Hand,  of  Brooklyn,  in 
which  an  irreducible  femoral  hernia  became  the  site  of  inflammation  due 
to  an  inflamed  appendix  which  it  contained.  Sir  F.  Treves  met  with  a 
case  in  which  the  appendix,  the  seat  of  recurrent  trouble,  occupied  an 
inguinal  sac.  (10)  Communication  with  the  rectum,  bladder,  or  vagina. 
(11)  Septicemia.  This  may  supervene,  as  on  one  of  the  last-mentioned 
complications,  quite  apart  from  suppurative  peritonitis.  (12)  Abscess 
in  the  abdominal  wall,  causing  most  extensive  burrowing.  (13)  Stitch 
sinus.  (14)  Ventral  hernia.  (15)  Thrombosis  of  the  femoral  vein. 
Dr.  Meyer  describes  two  cases  of  this  {Ann.  of  Sun/.,  May,  1 901). 


PERFORATION    OF    GASTRIC   ULCER.* 

The  perforation  may  either  be  acute,  associated  with  sudden  escape  of 
gastric  contents  into  the  general  peritonseal  cavity,  or  chronic,  resulting 
in  the  formation  of  a  localised  abscess. 

A.  Acute  Perforation. — The  successful  treatment  of  these  most  fatal 
lesions  depends  w^on  early  operation. 

This  should  be  performed  as  soon  as  possible  after  the  accident,  delay 
only  leading  to  the  additional  escape  of  septic  material,  especially  if  the 
patient  has  been  moved  about.  Another  urgent  reason  for  early  opera- 
tion is  the  fact  that  the  later  the  operation  is  deferred,  the  more  diflicult 
it  is,  and  the  less  is  the  patient  able  to  bear  the  necessarily  prolonged 
interference.  Again,  the  longer  the  dela}',  the  greater  is  the  tendency 
to  the  formation  of  masses  of  l3'mph,  which  may  conceal  the  ulcer, 
mat  viscera  together,  and  so  form  culture-pools  for  bacteria,  and  hamper 
the  attempts  at  cleansing  the  peritonteum. 

While  the  surgeon  will  be  unwilling  to  interfere  during  the  period  of 
collapse  which  follows  on  the  perforation,  he  should  utilise  this  time  in 
making  the  needful  preparations.! 

It  seems  clear  that  while  ulcers  occur  most  frequently  on  the  posterior 
surface  of  the  stomach,  those  on  the  anterior  surface  are  most  liable  to 

*  This  is  placed  here  instead  of  under  the  Operations  on  the  Stomach,  first,  because, 
like  a  perforated  vermiform  appendix,  it  is  such  a  dangerous  source  of  peritonitis  ; 
secondly,  because  it  calls  for  the  same  treatment  as  the  less  common  duodenal  ulcer. 

t  A  hot-water  table,  water-bed,  and  hot  bottles  should  be  provided,  the  patient's 
limbs  bandaged  in  cotton-wool,  the  head  kept  low,  ether  given,  and  an  enema  of  port 
wine  administered:  injections  of  strychnine  anel  the  necessaries  for  saline  infusion 
should  also  be  at  hand. 


204  OPEEATIOXS  OX  THE  ABDOMEN. 

perforate.  Thus,  out  of  ninety  cases  operated  upon,  the  perforation  in 
eight}— six  was  on  the  anterior  surface ;  posterior  perforations  occurring 
only  in  eleven  cases.  Perforations  are  more  frequently  nearer  the  lesser 
than  the  greater  curvature,  and  the  cardia  than  the  pylorus.  This  last  fact 
is  one  of  much  practical  importance,  as  the  cardia  is  a  relatively  fixed 
point,  and  the  nearer  an  ulcer  is  to  this  end,  the  greater  is  the  difficulty 
in  suturing  it.  Finally,  it  should  be  remembered  that  in  several  cases 
there  have  been  moi'e  than  one  perforation.  Finney  (Ann.  of  Surr/., 
July  1900)  says  that  in  20  per  cent,  of  the  cases  there  is  a  second 
perforation. 

The  operation  itself  includes  :  i.  Finding  the  perforation  ;  ii.  Success- 
fully closing  it ;  iii.  Efficiently  cleansing  and  draining  the  peritonseal 
sac — headings  which  will  be  taken  separately. 

Operation. — The  parts  having  been  fitly  cleansed,  and  e\'ery  pre- 
caution taken  against  shock,  an  incision  four  to  five  inches  long  is 
made  in  the  middle  line  from  the  tip  of  the  xiphoid  cartilage  to  the 
umbilicus.  When  the  peritonasum  is  opened  an  escaj^e  of  gas  is  not 
uncommon;*  sometimes  of  fluid,  consisting  partly  of  the  last  meal 
taken,!  and  partly  of  serous  effusion  from  the  irritation  of  the  peri- 
tongeum. 

If  there  is  no  such  escape  the  outlook  is  so  far  more  favourable,  as  it 
may  be  hoped  that  as  yet  the  effusion  is  slight,  and  limited  to  part  only 
of  the  jDeritonreal  sac.  If  this  be  so,  though  it  is  uncommon,  the  surgeon 
should  shut  off"  the  lower  part  of  this  sac  as  far  as  possible  with  gauze 
tampons  or  flat  sponges  before  he  disturbs  the  stomach  and  its  sur- 
roundings. 

i.  Finding  the  Perforation. — This  varies  very  much  in  difficulty. 
Sometimes  the  eye  detects  it  at  once  when  the  stomach  is  drawn  down 
(hj  gently  pulling  on  the  omentum,  if  need  be)  and  the  edges  of  the 
wound  retracted.  At  other  times  the  exj)loring  finger  soon  feels  it  or 
the  area  of  induration  which  forms  the  base  of  the  ulcer.  In  other  cases 
finding  the  ulcer  is  beset  with  the  greatest  difficulty,  or,  owing  to  the 
hurried  search  which  alone  is  possible  from  the  state  of  the  patient,  is 
quite  impossible.  In  a  difficult  case  help  may  be  obtained  by  tracing 
the  direction  in  which  the  congestion  of  the  stomach  appears  to  be 
increasing,  by  watching  the  direction  from  which  any  flow  that  may  be 
present  is  coming,  or,  acting  on  a  suggestion  which  has  been  made  of 
injecting  air  through  an  oesophageal  tube,  that  the  escaping  bubbles 
may  lead  to  the  ulcer.  If  a  careful  search  over  the  anterior  surface  of 
the  stomach  fail,  the  liver  should  be  raised  by  an  assistant,  and  the 
lesser  curvature  examined  with  a  good  light.  Adherent  lymph  or 
adhesions  betA\een  the  stomach  and  liver  may  mark  the  site  of  the 
perforation,  and  require  gentle  separation  before  it  is   revealed.     The 

*  If  it  is  a  late  case,  as  in  one  I  mention  (p.  208),  the  tympanites  and  distended 
intestines  may  be  most  embarrassing.  In  one  published  by  Dr.  Anson  (^Lancet,  vol.  i. 
1893,  p.  469),  the  distension  all  subsided  after  a  rush  of  odourless  gas  when  the  abdo- 
men was  opened. 

t  The  interval  that  has  elapsed  is  most  important.  Thus,  in  a  successful  case 
published  by  Dr.  Walter,  of  Reading  (^Lancet,  vol.  i.  1S95,  p.  484),  five  hours  had 
elapsed.  So,  too,  in  a  case  of  Dr.  W.  Hall's  (JBrit.  Med.  Joiirn.,  vol.  i.  1892,  p.  64) 
which  recovered  without  operation  after  very  severe  peritonitis,  the  interval  was  four 
hours. 


PERFORATION  OF  GASTRIC  ULCER.  205 

perforation  itself  may  be  extremelj'  small,  and  thus  easily  hidden  by  any 
fold  of  the  stomach,  still  more  readily  by  lymph  and  adhesions. 

Mr.  Dunn's  case  {loc.  infra  cit.)  well  shows  how  difficulty  here  is 
to  be  met : 

On  separating  the  adhesions  which  fixed  the  liver  to  the  abdominal  -wall,  a  quantity 
of  opalescent  fluid  escaped.  The  liver  was  then  pulled  upwards  and  the  anterior  wall 
of  the  stomach  pushed  backwards,  and  now  it  was  that  some  brownish  fluid  like  weak 
coffee,  containing  gas-bubbles  and  one  or  two  small  masses  of  coagulated  milk,  escaped. 
It  welled  up  from  a  considerable  depth,  at  the  left  of  the  incision,  and  was  found,  on 
subsequent  examination,  to  be  strongly  acid,  and  to  contain  a  little  albumen,  Several 
more  adhesions  wei'e  broken  down,  but  still  no  perforation  could  be  seen,  and  it  was 
only  when  the  left  margin  of  the  wound  was  stretched  outwards  to  the  utmost,  whilst 
steady  traction  was  made  upon  the  stomach  towards  the  right,  that  the  hole  in  this 
viscus  became  visible. 

At  this  stage,  or  a  little  later,  to  facilitate  the  suturing,  it  may  be 
necessary  to  divide  the  left  rectus,  in  order  to  get  more  room.  Save 
for  weakening  the  abdominal  wall  this  step  is  a  light  one,  as  long  as 
the  intestines  are  not  distended.  If  distension  is  present  it  is  a  serious 
complication,  as  it  facilitates  very  much  the  escape  of  the  intestines. 

ii.  Closure  of  the  Perforation. — It  has  been  suggested  that,  before 
this  is  done,  the  stomach  should  be  emptied  and  washed  out.  If  the 
perforation  has  been  cjuickly  found,  if  the  patient's  condition  is  good, 
and  if  the  stomach  can  be  got  well  outside  the  wound,  emptying  b}* 
gentle  squeezing  will  be  beneficial,  by  preventing  vomiting,  and  thus  a 
strain  on  the  sutures.  So,  too,  with  regard  to  washing  out  the  viscus, 
if  a  drainage-tube  can  be  readily  inserted  through  the  perforation. 
But  the  small  size  of  the  external  opening  will  often  prevent  this ; 
and  with  regard  both  to  emptying  and  washing  out  the  stomach,  it 
is  certain  that  in  neither  case  will  the  advantages  gained  counter- 
balance the  loss  of  time,  that  would  have  been  better  spent  later  on, 
in  thoroughly  washing  out  the  peritoneal  cavity. 

With  regard  to  excising  the  ulcer,  which  has  been  recommended,  the 
same  conditions  and  objections  apph'.  Much  extra  time  will  be  con- 
sumed, there  may  be  a  good  deal  of  additional  haemorrhage,  and  the 
perforation  converted  into  a  large  gap  requiring  numerous  sutures  to 
close  it  (Swain,  Lancet,  vol.  ii.  1894,  p.  22).  In  this  case  much  difficulty 
was  met  in  inverting  the  pouting  mucous  coat.  Moreover,  the  success- 
ful cases  treated  b}'  suture  without  excision  show  that  this  step  is  not 
needful.  If  the  perforation  is  si^illing  its  contents  when  seen,  a  finger 
or  sponge  in  a  holder  should  be  placed  upon  it,  or  a  silk  suture  passed 
across  its  centre  so  as  to  prevent  further  escape.  The  perforation,  having 
been  shut  off  with  iodoform  gauze  tampons,  it  is  next  carefully  closed 
with  Lembert's  sutures  of  sterilised  silk.*  One  row  of  these  will  suffice 
if  inserted  with  the  following  precautions :  They  should  begin  and  end 
well  beyond  the  extremities  of  the  perforation  (Fig.  55).  They  should 
take  up  the  coats  of  the  stomach  as  far  as,  but  not  be\^ond,  the  sub- 
mucous layer.  They  should  be  inserted  far  enough  from  the  margins 
of  the  perforation  to  ensure  sufficient  inversion  of  the  serous  surfaces 
when  the  sutures  are  tightened,  and  this  inversion  may  be  aided  by  a 

*  The  passage  of  these  may  be  facilitated  by  the  use  of  two  guide-stitches  of 
medium-sized  silk,  passed  a  full  inch  from  the  edges  of  the  perforation,  as  used  by 
Mr.  Gould  in  his  case. 


206  OPERATIONS  ON  THE  ABDOMEN. 

probe  or  director.  All  the  sutures  should  be  inserted  before  any  are 
tied.  If  any  cut  out  as  they  are  fastened,  fresh  ones  must  be  re-inserted 
at  a  sufficient  distance  from  the  margins  of  the  perforation  to  give 
a  firm  hold,  and  a  second  set  must  be  employed  where  the  union  is 
certainly  weak. 

Whenever  it  is  feasible  the  suturing  should  be  performed  with  the 
viscus  outside  the  wound,  this  part  of  the  stomach  resting  on  hot 
carbolised  towels  or  tampons  of  sterile  gauze.*  When  it  is  not  pos- 
sible to  bring  the  stomach  outside,  the  difliculties  are  greatly  increased, 
especially  if  the  perforation  be  near  the  cardia,  a  more  fixed  part.  Here, 
drawing  up  the  margin  of  the  ribs  and  liver,  pulling  down  the  stomach, 
or  division  of  the  left  rectus  may  be  of  service. 

Where  either  the  position  of  the  ulcer  or  the  amount  of  surrounding 
induration  makes  it  impossible  to  close  a  perforation  with  sutures,  one  of 
the  following  courses  should  be  followed:  (i)  A  piece  of  omentum  may 
be  used  to  close  the  opening,  being  kept  in  position  by  means  of  careful 
suturing.  (2)  If  the  ulcer  lies  under  cover  of  the  liver  it  may  be  possible 
to  fix  this  down,  over  the  perforation,  by  means  of  sutures.  (3)  A 
closely  fitting  drainage-tube  should  be  passed  into  the  perforation  to 
draw  off  all  remaining  food  and  secretion,  and  then  the  space  between 
the  stomach  and  the  abdominal  wall  should  be  closed  all  around  the 
tube  with  strips  of  iodoform  gauze,  so  as  to  promote  adhesions.  (4)  A 
less  satisfactory  plan  is  to  stitch  the  margins  of  the  perforation  to  the 
edges  of  the  wound  in  the  abdominal  wall  and  treat  it  as  a  gastric 
fistula,  the  rest  of  the  wound  being  firmly  closed  round  it. 

So  far  I  have  spoken  of  ulcers  on  the  anteriw  surface  of  the  stomach. 
The  rarer  but  much  less  accessible  ones  on  the  posterior  surface  must 
now  be  referred  to.  As  is  well  kno\A'n,  while  gastric  ulcers  are  much 
more  frequently  met  with  on  this  surface,  these  rarely  perforate,  owing 
to  the  tendency  for  adhesions  to  form  between  this  surface  of  the  stomach 
and  the  pancreas.  If  the  evidence  of  perforation  is  strong,  and  nothing 
can  be  found  on  the  anterior  surface  or  lesser  curvature,  the  surgeon 
can  examine  the  posterior  wall  by  (a)  carefully  tearing  through  the 
lesser  omentum  and  inverting  the  anterior  wall ;  the  posterior  one 
comes  into  view  through  the  hole  made  in  the  lesser  omentum  ;t  (h)  by 
tearing  through  the  great  omentum,  (c)  by  passing  the  finger  through 
the  foramen  of  Winslow. 

In  a  case,  under  the  care  of  Dr.  L.  E.  Shaw,  I  adopted  the  first  of  the  above  plans. 
The  operation  was  performed  seventeen  hours  after  the  perforation.  As  no  perfora- 
tion could  be  found  on  the  anterior  surface  of  the  stomach,  the  lesser  omentum  was 
carefully  torn  through  and  the  posterior  surface  explored.  A  small,  recent-looking  ulcer 
was  found  near  the  lesser  curvature,  with  a  small  perforation  in  its  centre.  With 
considerable  difficulty  six  Lembert's  sutures  were  inserted  so  as  to  invert  the  ulcer. 
Irrigation  was  not  performed,  but  free  drainage  was  employed,  a  Keith's  tube  being 
placed  in  the  pelvis,  and  a  tube  and  gauze  strips  passed  down  to  the  lesser  curvature. 
The  patient  made  a  good  recovery. 

*  Whenever  during  an  abdominal  section  it  is  necessary  to  keep  viscera  outside, 
it  should  be  the  duty  of  one  assistant  to  see  that  their  temperature  is  maintained  and 
that  their  surroundings  are  aseptic  only,  and  it  should  be  the  duty  of  a  separate  nurse 
to  help  in  this. 

Mr.  J.  E.  Morrison,  of  Newcastle,  adopted  this  plan  QBrit.  Med.  Journ.,  vol.  ii. 
1894,  P-  864).  The  patient  survived  till  the  ninth  day,  and  at  the  necropsy  the  peri- 
tonitis was  limited  to  the  pelvis. 


PERFORATION  OF  GASTRIC  ULCER.  207 

iii.  Cleansing  of  the  Peritonseal  Sac. — Though  most  stress  has  been 
laid  iipon  the  point  of  efficient  suturing  of  the  perforation,  there  is  no 
doulot  that  this  one  is  quite  as  important.  The  fluid  used  should  be 
boiled  water  or  saline  infusion,  ejj.,  sod.  chlor.  3j- — Qj.  of  boiled  water 
at  a  temperature  of  105"'  to  i  lo'"'.  If  no  irrigator  is  at  hand  a  glass  tube 
or  the  end  of  an  resophagus-tube.  attached  to  india-rubber  tubing  (all 
having  been  sterilised)  and  arranged  as  a  syphon  or  attached  to  a  funnel, 
will  answer  very  well.  Failing  this,  a  clean  Higginson's  syringe  will 
suffice,  if  some  one  else  pumps  in  the  fluid  so  as  to  set  free  both  the 
surgeon's  hands  for  the  delivery  and  distribution  of  the  fluid.  The 
cleansing  must  be  systematic,  persevering,  and  thorough.  The  whole 
cavity  must  be  gone  over  in  a  regular  way,  and  there  is  no  better 
method  than  that  given  by  Dr.  Maclaren,  who  has  operated  in  three 
cases,  in  one  with  success  {Brit.  Med.  Journ.,  vol.  ii.  1894): 

••  The  plan  I  take  is  to  begin  with  the  neighbourhood  of  the  rupture,  wash  it  well ; 
then  starting  from  this  as  a  centre,  to  make  the  nozzle  follow  the  course  of  the  colon, 
first  towards  the  csecum,  specially  cleaning  out  below  the  liver ;  secondly,  starting 
again  from  the  stomach,  to  follow  the  great  bowel  to  the  rectum.  In  this  latter  course 
the  lumbar  and  pelvic  hollows  should  receive  special  care.  Finally,  the  douche  is 
<lirected  among  the  folds  of  the  mesenteric  attachments  of  the  small  intestines.  I  have 
repeatedly  noticed  here,  when  all  seemed  clear,  that  a  fresh  turn  of  the  instrument 
would  empty  some  unsuspected  pocket." 

If  the  extravasation  is  limited,  as  it  may  be  in  very  early  cases,  it  is 
wiser  not  to  irrigate,  as  this  may  do  more  harm  than  good.  The  soiled 
portion  of  the  i^eritonasum  should  be  carefully  cleansed  with  soft  mops 
of  sterilised  gauze,  care  being  taken,  on  the  one  hand,  to  cleanse  the 
parts  as  thoroughly  as  possible,  and,  on  the  other  hand,  to  avoid 
damage  to  the  peritonseum  by  using  undue  force. 

Some  surgeons  prefer  to  trust  entirely  to  mopping  in  this  way  with- 
out using  irrigation  at  all;  for  instance,  Mr.  Barker  (Clin.  Soe.  Traaa., 
1900),  who  gives  a  list  of  twelve  cases  treated  by  mopping  alone,  with 
five  recoveries.  It  would  seem,  however,  wiser  on  the  whole  to  irrigate 
thoroughly  when  the  general  peritonaeal  cavity  is  contaminated,  supple- 
menting this,  if  necessary,  with  careful  wiping  to  get  rid  of  any  coarser 
particles  that  may  be  visible,  and  to  trust  entirely  to  wiping  onlv  when 
the  extravasation  is  localised. 

Before  closing  the  abdominal  wound  the  question  of  drainage  ^\■ill 
arise.  The  necessity  for  this  largely  depends  upon  the  particular  con- 
ditions found  at  the  operation.  If  the  case  has  been  operated  upon 
quite  early,  if  the  amount  of  extravasation  is  small  and  limited,  and  the 
area  thoroughly  cleansed,  the  abdominal  wound  may  be  closed  without 
drainage.  In  the  great  majority  of  cases,  however,  drainage  Avill  be 
necessary.  Usually  gauze  drains  passing  in  various  directions  from  the 
abdominal  incision  will  meet  all  requirements :  one  sliould  pass  down 
to  the  seat  of  perforation ;  another  upwards  between  the  stomach, 
liver,  and  gall-bladder ;  and  another  downwards  beneath  the  abdominal 
wall  towards  the  umbilicus.  Others  may  be  added  if  thought  advisable. 
If  extensive  extravasation  implicating  practically  the  whole  abdominal 
cavity  has  taken  place,  a  tube  should  be  passed  down  into  the  pelvis 
through  a  small  incision  above  the  pubes,  in  addition  to  the  gauze  drains. 

Rectal  feeding  must  be  employed  for  at  least  forty-eight  hours, 
nothing  being  given  by  the  mouth  during  this  time  save  sips  of  tepid 


208  OPERATIONS  ON  THE  ABDOMEX. 

water.  It  will  be  well  to  watch  these  cases  for  a  long  time  after.  Thus, 
Mr.  Silcock  reports  a  case  treated  successfully  by  drainage,  the  ulcer 
not  being  found  :  the  patient  "  has  suffered  since  from  impaired  locomo- 
tion of  the  stomach,  and  has  been  from  time  to  time  under  treatment 
as  an  out-  or  in-patient."' 

Causes  of  Failure, — In  every  new  operation  especially  it  is  well  to 
bear  these  in  mind.  The  chief  are  :  (i)  Peritonitis  existing  before,  and 
not  removed  by,  the  operation.  This  has  been  the  most  frequent  cause 
of  death.  It  was  so  in  two  cases  on  which  I  operated.  Both  were  under 
the  care  of  Dr.  Newton  Pitt : 

In  the  first,  the  sj'mptoms  of  shock  and  peritonitis  were  distinctly  subacute  and 
slightly  marked.  My  colleague,  however,  was  sure  of  his  diagnosis,  and  when  the 
abdomen  was  opened  an  open  nicer  was  easily  seen  on  the  anterior  surface,  from  which 
a  greyish  liquid  was  continuously  gushing.  On  bringing  the  perforation  outside  the 
abdomen,  the  opening  was  felt  to  be  surrounded  by  a  large  callous  base.  Death  took 
place  from  peritonitis  forty-eight  hours  later  ;  at  the  necropsy  the  ulcer  was  found 
firmly  sutured.  In  the  second  case  operation  was  refused  at  first  when  urged  upon  the 
patient,  and  it  was  not  until  the  third  day,  when  the  abdomen  was  greatly  distended, 
tympanitic,  and  motionless,  that  the  patient  and  her  friends,  seeing  how  hopeless  the 
case  was  getting,  gave  their  consent.  When  the  abdomen  w^as  opened  the  stomach 
itself  was  greatly  distended.  The  peritonseal  sac,  especially  at  its  upper  part  under  the 
liver,  between  this  and  colon,  spleen,  and  kidneys,  was  filled  with  purulent  fluid, 
in  which  the  more  solid  part  of  the  last  meal  taken  (Scotch  broth)  could  be  seen  floating. 
All  the  viscera  seen  were  thickly  scattered  with  thick  yellowish  flaky  lymph.  This  was 
especially  present,  together  with  numerous  soft  adhesions,  between  the  lesser  curvature 
and  the  liver.  Had  I  broken  down  and  searched  amongst  these  I  should  have  found 
the  ulcer,*  but  the  anterior  surface  being  sound,  and  the  stomach  greatly  distended,  I 
examined  the  duodenum  and  found,  as  I  thought,  a  minute  perforation,  a  softened  spot 
on  the  anterior  and  inner  part  of  the  first  portion,  into  which  a  probe  passed.  This  I 
sutured,  and  sponged  and  washed  out  the  peritonseal  sac.  The  patient  was  in  a  most 
critical  state  at  the  time  of  the  operation,  and  sank  thirty-eight  hours  after.  At  the 
necropsy  a  perforation  was  found  on  the  lesser  curvature. 

(2)  Shock  of  the  operation  and  ansesthetic.  (3)  Abscess  between  the 
stomach  and  liver  causing  septicaemia  or  leading  to  empyema  : 

The  treatment  must  be  efficient  drainage  ;  an  incision  being  made  in  front,  in  the 
middle  line  or  over  any  epigastric  prominence.  Drainage  should  also  be  afforded 
behind  by  resection  of  one  or  more  ribs  QLancet,  vol.  i.  1893,  P-  145);  o^  ^  glass  drain- 
age-tube be  employed  as  in  a  case  of  Dr.  Ewart  and  Mr.  Bennett's  (^Lancet,  vol.  ii.  1894, 
p.  1 14  7).      Vide  also  chronic  perforation,  p.  209. 

(4)  A  second  perforation.  This  is  stated  by  Finney  {loc.  siq^ra  cit.)  to 
be  present  in  20  per  cent,  of  the  cases,  and  a  careful  search  should  there- 
fore always  be  made  for  a  second  ulcer.  Again,  a  second  perforation 
may  take  place  after  the  operation,  for  when  the  ulcer  is  very  large 
another  spot  may  give  wa}^,  probably  from  softening  set  iip  by  the  local 
inflammation  due  to  suturing. 

Mr.  Gould  (_Brit.  Med.  Journ.,  vol.  ii.  1894,  p.  ?6i)  mentions  a  case  of  Mr.  Pepper's  in 
which  a  perforation  had  been  sutured.  For  three  days  the  patient  did  well,  when  she 
suddenly  became  collapsed  and  quickly  died.  The  necropsy  showed  that  the  perforation 
which  had  been  sutured  was  in  the  front  part  of  an  iilcer  the  size  of  a  crown-piece,  the 
line  of  suture  being  perfect  and  water-tight,  but  that  a  second  perforation  had  occurred 
at  its  posterior  part. 

*  No  surgeon  should  leave  these  unexplored  in  the  hope  of  a  natural  cure.  This,  if 
accomplished,  will  very  likely  be  so  at  the  cost  of  a  sub-phrenic  abscess  and  septicsemia. 
See  also  the  remarks  above. 


PERFORATIOX  OF  GASTRIC  ULCER. 


209 


B.  Chronic  Perforation. — Instead  of  sudden  perforation,  with  escape 
of  the  contents  of  the  stomach  into  the  general  peritonseal  cavit}^,  the 
perforation  here  is  associated  with  the  formation  of  adhesions  and  the 
production  of  a  locaHsed  abscess.    This  may  be  brought  about  in  several 

Fig.  47. 


■j-PANCREflS 
PERFORATIOrj 


-uuoDEr,xi:,i 


\f 


PANCREAS 
-(S'PCRFCR.UiaN 


Diagram  of  sub-phrenic  abscess  from 
perforation  of  the  anterior  wall  of 
the  stomach.     (Greig  Smith.) 


Diagi-am  of  sub-phrenic  abscess  from 
perforation  of  the  posterior  wall  of 
the  stomach.     (Greig  Smith.) 


ways.  In  some  cases  the  base  of  the  ulcer  becomes  adherent  to  a  viscus 
— liver,  spleen,  or  pancreas, — subsequent  perforation  giving  rise  to  an 
abscess  which  slowly  burrows  first  into  and  then  beyond  the  viscus  in- 
volved.   In  other  cases,  the  perforation  is  preceded  by  a  plastic  peritonitis 

Fig.  49. 


Diagram  of  retro-peritonaeal  sub-phrenic  abscess.     (Greig  Smith.) 


resulting  in  the  formation  of  adhesions,  which  thus  limit  the  diffusion 
of  gastric  contents  when  perforation  occurs.  Again,  the  leakage  of 
gastric  contents  may  at  first  only  take  place  quite  slowly,  owing  either 
to  the  small  size  of  the  perforation,  to  the  stomach  being  empty  at 
VOL.  II.  14 


2IO  OPERATIONS  OX  THE  ABDOMEN. 

the  time,  or  to  the  perforation  taking  place  during  the  night.  The 
abscess  so  produced  is  in  most  instances  of  the  siihijhrenic  variety,  the 
majority  of  which  are  caused  by  gastric  ulcers. 

The  limits  of  the  abscess  vary  according  to  the  site  of  the  perforation, 
as  will  be  understood  by  reference  to  the  accompanying  illustrations. 
Fig.  47  shows  the  boundaries  of  an  abscess  produced  by  perforation  of 
an  ulcer  in  the  anterior  wall  of  the  stomach.  It  will  be  seen  to  be 
limited  below  by  adhesions  between  the  great  omentum  and  the  anterior 
abdominal  wall,  and  above  by  the  diaphragm  and  anterior  layer  of  the 
coronary  ligament  of  the  liver.  Usually  the  abscess  involves  one  side 
only,  being  bounded  internally  by  the  falciform  ligament  of  the  liver. 
In  Fig.  48  is  shown  an  abscess  produced  by  a  perforation  in  the  posterior 
wall  of  the  stomach.  Here  the  abscess  cavity  involves  the  lesser  sac  of 
the  peritongeum,  the  foramen  of  Winslow  being  occluded  by  adhesions. 
The  third  variety,  sho\\Ti  in  Fig.  49,  will  be  seen  to  be  in  reality  a  retro- 
periton^eal  abscess.  Such  an  abscess  will  be  caused  by  a  perforation 
in  the  posterior  wall  of  the  stomach,  where  the  two  walls  of  the  lesser 
sac  of  the  peritonteum  have  previously  become  adherent,  or,  in  some 
cases,  by  pei'foration  of  a  duodenal  ulcer. 

Operation. — The  treatment  of  the  condition  resolves  itself  into  drain- 
age of  the  abscess,  any  attempt  at  closing  the  perforation  in  the  stomach 
being  generally  out  of  the  question. 

If  a  diagnosis  of  sub-phrenic  abscess  has  been  made,  and  the  limits 
of  the  abscess  can  be  ascertained,  it  may  be  opened  through  the  lower 
part  of  the  chest  wall,  portions  of  one  or  more  ribs  being  resected.  Care 
must,  however,  be  taken  to  prevent  infection  of  the  pleural  cavity,  by 
suturing  the  two  laj'ers  of  the  pleura  to  one  another,  if  these  are 
not  found  to  be  already  adherent.  The  abscess  may  then  be  reached  by 
pushing  a  director  through  the  diaphragm  and  enlarging  the  opening 
with  dressing-forceps.  In  the  majority  of  cases,  however,  the  condition 
will  be  first  discovered  on  exploring  the  abdomen  by  means  of  a  median 
incision.  If  the  abscess  is  of  the  first  variety,  it  will  be  opened  at  once 
on  dividing  the  peritongeum,  and  may  be  drained  entirely  through  the 
anterior  incision,  or  a  counter-puncture  may  be  made  in  the  side. 
Should  the  abscess  involve  the  lesser  sac  of  the  peritonaeum,  it  rnay  be 
opened  through  the  gastro-hepatic  omentum  after  the  general  peritonasal 
cavity  has  been  shut  off  by  careful  packing  with  iodoform  gauze. 

Infection  of  the  general  peritonteal  cavity  can  be  avoided  either  by 
drawing  off  the  pus  with  an  aspirator,  or  hj  making  only  a  small 
opening  and  then  carefully  mopping  up  the  pus  as  fast  as  it  escapes. 
After  the  cavity  has  been  completely  emptied  and  wiped  as  clean  as 
possible,  it  must  be  explored  by  the  finger,  and  a  counter-opening  for 
drainage  made  in  the  side.  The  soiled  gauze  surrounding  the  anterior 
opening  is  now  replaced  by  clean  iodoform  gauze,  and  the  wound  partU^ 
closed. 

PERFORATING    DUODENAL    ULCER.* 

Very  little  need  be  added  here  to  the  account  jvist  given.  This  form 
of  ulcer  occurs  most  frequently  in   men,   and   perforation  may  cause 

*  My  readers  will  find  cases  recorded  by  Mr.  Lockwood,  Lancet,  vol.  ii.  1894,  p.  969 ; 
Mr.  Eve,  ihid.,  p.  1092  ;  and  Mr.  Shield,  Hid.,  vol.  i.  1895,  p.  1169. 


PERFORATION  OF  TYPHOID  ULCER.  211 

symptoms  indistinguishable  from  those  of  acute  intestinal  obstruction 
(Lockwoofl).  The  only  hope  is  that  the  case  may  be  seen  early,  and 
evidence  obtained  that  the  pain  felt  was  at  first  epigastric,  and  any  early 
tenderness  referred  to  the  right  epigastrium. 

Operation. — Where  no  such  information  is  at  hand,  the  surgeon  will 
make  a  free  median  incision  with  its  centre  at  the  umbilicus ;  the 
appendix,  Fallopian  tubes,  &c.,  will  be  found  healthy ;  perhaps  an  escape 
of  gas  will  take  place  when  the  peritonaeal  sac  is  opened,  and  it  maj^  be 
noticed  that  the  fluid  which  is  the  cause  of  the  peritonitis  is  not  faecal 
in  character.*  If  the  operation  be  early  the  fluid  may  give  an  acid 
reaction,  if  time  have  not  elapsed  for  this  to  be  neutralised  by  the 
secondar}^  peritoneeal  eff'usion. 

The  ulcer  is  most  commonh'  met  with  on  the  anterior  aspect  of  the 
first  piece,  and  is  thus  accessible.  Sometimes  it  is  on  the  posterior 
surface,  as  in  one  of  Mr.  Lockwood's  cases  in  which  the  necropsy  showed 
that  it  would  not  have  been  seen  at  an  abdominal  exploration. t  In  the 
further  details  and  essentials  of  the  operation  the  account  alread}"  fully 
given  for  the  treatment  of  the  much  more  frequently  perforating  gastric 
ulcer  must  be  closely  followed. 


PERFORATION    OF    TYPHOID    ULCER. 

The  results  of  operation  for  this  condition  have  during  recent  years 
undergone  a  steady  improvement.  In  a  list  of  eighty-three  cases  which 
Keen  {Surgical  ComiMcations  and  Sequelce  of  Typhoid  Fever)  gives,  there 
were  sixteen  recoveries  ;  ig'2  per  cent,  of  the  operations,  therefore,  were 
successful. 

This  improvement  is  doubtless  largely  due  to  earlier  diagnosis  of  the 
condition,  and  therefore  earlier  operation ;  and  as  the  feasibility  of  the 
operation  becomes  more  fulh'  recognised  by  physicians  and  surgeons 
alike,  a  still  greater  proportion  of  successes  will  no  doubt  be  obtained. 
Keen  maj"  be  quoted  on  this  point;  he  says — "When  once  the  physi- 
cians are  not  only  on  the  alert  to  observe  the  symptoms  of  perforation, 
but  when  the  knowledge  that  perforation  of  the  bowel  can  be  remedied 
by  surgical  means  has  permeated  the  profession,  so  that  the  instant  that 
perforation  takes  place  the  surgeon  will  be  called  upon,  and,  if  the  case 
be  suitable,  will  operate,  we  shall  find  unquestionably  a  much  larger 
percentage  of  cures  than  have  thus  far  been  reported."  But,  although 
earlier  diagnosis  will  do  much  to  render  these  cases  more  hopeful,  it 
must  not  be  forgotten  that  many  of  them  will  still  be  practically  hope- 
less from  the  first,  both  on  account  of  the  serious  condition  of  the  patient 
and  of  the  technical  difficulties  which  the  surgeon  will  have  to  face. 
Some  of  the  cases  mentioned  later — for  instance,  those  of  Thomas  and 
Allingham — serve  to  emphasise  the  latter  point. 

The  cases  may  be  divided  into  two  diSerent   classes — the  first,   in 

*  That  this  is  not  ahvays  so  is  shown  by  Mr.  Eve's  case.  The  fluid  is  described  as 
■•  scro-purulent  with  a  faecal  odonr  "  and  as  "  purulent  fascal  fluid." 

t  So,  too,  in  a  specimen  brought  by  Dr.  Pye-Sniith  before  the  Patliological  Society 
(Lancet,  vol.  ii.  1893,  P-  ^443)?  i*  is  distinctly  stated  that  the  ulcer  could  not  have  been 
reached  by  operation. 


212  OPEEATIONS  ON   THE  ABDOMEN. 

whicli  perforation  takes  place  during  the  height  of  a  severe  attack  ;  the 
second,  in  which  the  perforation  occiirs  during  convalescence  or  a  mild 
relapse.  In  the  former  class  the  prospect  is  almost  hopeless  from  the 
first ;  in  the  latter,  however,  there  is  a  considerable  chance  of  success. 

Two  anatomical  points  should  be  remembered  in  connection  with 
operation.  The  first  is,  that  the  perforation  nearly  always  occurs  in  the 
last  few  feet  of  the  ileum ;  according  to  Keen  it  is  in  the  ileum  in 
8 1  "4  per  cent,  of  the  cases.  The  other  point  is,  that  more  than  one 
perforation  may  be  present.  In  Keen's  list  there  were  two  or  more 
perforations  in   i&y  per  cent. 

Operation. — This  must  be  carried  out  on  the  same  lines  as  those 
described  for  perforation  of  a  gastric  ulcer.  Every  precaution  having 
been  taken  against  shock,  an  incision  is  made  in  the  middle  line,*  begin- 
ning a  little  above  the  pubes  and  continued  upwards  sufficientl}^  high 
above  the  umbilicus.  When  the  peritoneum  is  opened  the  csecum 
must  be  taken  as  a  guide  to  the  lower  end  of  the  ileum.!  Enlarged 
mesenteric  glands  or  zones  of  intense  inflammation  may  also  be  guides 
to  the  perforation.  As  soon  as  this  is  found  the  coil  should  be  safely 
brought  outside  the  abdomen,  packed  around  with  hot  sterilised  towels 
or  gauze  tampons,  and  the  perforation  closed  according  to  the  general 
and  local  conditions  which  the  surgeon  has  to  face.  Thus,  (i)  if  the 
perforation  is  single,  small,  and  the  surrounding  intestine  in  a  condition 
to  hold  sutures,  the  perforation  should  be  closed  with  sterilised  silk,  a 
continuous  suture  first,  and  then  Lembert's  sutures  if  there  be  time. 

(2)  If  it  is  clear  that  the  tissues  are  too  friable  to  hold  sutures,  either 
the  perforation  must  be  excised — a   plan  adopted  by  Mr.   Sutton — or 

(3)  the  pei'foration  must  be  brought  a  little  outside  the  abdominal  wound 
and  fixed  by  sutures  which  take  up  healthy  bowel.  Later  on  this  artifi- 
cial anus  can  be  closed.  (4)  Where  the  mischief  is  very  extensive,  part 
of  the  intestine  may  be  removed,  and  the  ends  united  b}^  a  Murphy's 
button,  or  both  brought  outside  and  Paul's  tubes  placed  in  them  (vide 
infra). 

In  a  case  recorded  by  Dr.  Thomson,  of  Texas  {Med.  Ghron.,  Sept. 
1895),  ^^^6  caecum  was  so  disorganised  as  to  require  removal.  The  twa 
ends  were  brought  outside.  Death  took  place  eight  hours  later. 
Another  case,  showing  how  terribly  altered  the  tissues  with  which  we 
have  to  deal  may  be,  is  mentioned  by  Mr.  H.  Allingham  (Lancet,  vol.  i. 
1894,  p.  675).  Here  the  ileum  was  adherent  to  the  sigmoid  flexure  and 
tore  to  pieces  when  touched.  Suturing  of  the  j^erforation  being  impos- 
sible, it  was  fixed  in  the  wound.  Death  occurred  twenty-four  hours 
later.  Liicke,  of  Strasburg  (Deut.  Zeit.  f.  Chir.,'Bd.  xxv.  Hft.  i,  2,  Dec. 
1 886),  excised  a  wedge-shaped  piece  of  the  intestine.  The  operation  took 
nearly  two  hours,  and  the  patient  never  rallied,  dying  nineteen  hours  later. 

Owing  to  the  condition  of  the  patient  any  such  steps  as  suturing  and 
resection  will  be  quite  out  of  the  question  in  most  cases.     Perhaps  the 

*  Or  one  in  the  right  linea  semilunaris  may  be  chosen.  That  in  the  middle  line 
perhaps  gives  best  opportunities  for  systematic  irrigation. 

f  In  an  instructive  case,  nearly  successful,  as  the  patient  lived  until  the  sixth 
day  after  the  operation,  under  the  care  of  Dr.  Cayley  and  Mr.  Bland  Sutton  QClin. 
Soc.  Trans.,  vol.  xxvii.  p.  137),  the  loop  with  the  perforation  in  it  was  found  in  the 
pelvis. 


ABDOMINAL  SECTION  IN  PERITONITIS.  213 

plan  that  \\ill  give  most  successes  will  be  to  keep  the  perforation  outside 
while  the  peritonseal  sac  is  being  thoroughly  irrigated,  and,  a  day  or  two 
later,  to  deal  with  it  by  suture,  or  resection.  Liicke,  whose  fatal  case 
of  resection  I  have  referred  to,  advises  that  this  step  should  be  performed 
in  two  stages. 

ABDOMINAL    SECTION    IN    PERITONITIS. 

A.  In  Septic  Peritonitis. 

In  dealing  operativfly  with  a  case  of  peritonitis  the  surgeon  may  find 
the  following  classifications  useful : 

(A.)  CauHe* — i.  Feritonitis  set  vj^  hy  mischief  in  the  intestinal  tract, 
(uhether  accomjxmied  hy  perforation  or  not.  Instances  of  this  group 
would  be  hernia,  appendicitis,  intestinal  obstruction,  malignant  disease,  a 
caseating  mesenteric  gland,  gastric  ulcer,  duodenal  ulcer,  typhoid  perfor- 
ation, ii.  Peritonitis  set  up  hy  mischief  in  other  viscera  than  the  intestine, 
whether  accomjmnied  hy  a  perforation  or  not,  e.g.,  a  suppurating  ovarian 
cyst,  twisted  ovarian  pedicle,  salpingitis,  septic  metritis,  puerperal  perito- 
nitis,! ruptured  bladder,  suppurating  gall-bladder  or  spleen,  iii.  Trau- 
matic jJ&i'itonitis  from  tlie  efects  of  contusion,  gunshot  or  other  injuries 
(p.  281).  iv.  Tahercular  peritonitis.  This  last  will  be  taken  by  itself. 
(B.)  Extent  and  Progress. — In  the  first  three  classes,  which  are 
always  septic,  the  two  distinct  varieties  of  Mickulicz  (Centr.  f.  Chir., 
No.  29,  1889),  which,  though  they  run  into  each  other,  form  two  types, 
should  always  be  distinguished  in  practice,  viz.,  (i)  the  flifixse  septic 
peritonitis,  in  which  a  large  portion  of  the  peritonseal  surface  is  quickly 
infected,  and,  no  adhesions  being  formed,  the  infection  spreads  rapidly ; 
(2)  pi'ogressive  pjeritonitis,  where  the  peritongeum  is  only  afiected  at  first 
in  the  neighbourhood  of  the  cause.  This  focus  is  at  first  shut  off  by 
adhesions,  but  as  the  process  gradually  spreads,  larger  or  smaller  quan- 
tities of  purulent  exudation  are  encapsuled  between  the  glued  viscera. 
Mickulicz  thinks  that  the  treatment  in  the  two  must  be  different.  In 
the  first  the  whole  peritonaeum  must  be  disinfected  as  far  as  possible. 
In  the  second,  not  the  peritonaeum  in  its  whole  extent,  but  each  inter- 
peritonseal  focus  must  be  opened  separately. 

Operation. — We  will  take  here  a  case  where  the  septic  peritonitis 
is  diff'used,  where  the  surgeon  is  in  doubt  as  to  its  cause,  and  where  he 
is  met  by  that  combination  of  ominous  conditions  which  confront  us  in 
these  cases,  viz.,  peritonitis  and  eff'usion,  a  septic  condition,  distended 
paralysed  intestines,  and  exhaustion  from  pain,  vomiting,  &c. 

In  no  case  is  the  need  of  meeting  shock  more  imperatively  needed, 
viz.,  bandaging  the  limbs  in  cotton-wool,  a  hot-water  mattress,  or  hot 

*  It  is  plain,  I  think,  from  such  carefully  reported  cases  as  one  by  Dr.  S.  West  QClin. 
Soc.  Trans.,  vol.  xix.  p.  36),  that  cases  of  idiopathic  purulent  peritonitis  do,  very 
occasionally,  occur.  Dr.  Hilton  Fagge  (^(hiy's  Hosp.  BeX).,  1875)  stated  that  in  an 
experience  of  twenty  years  he  had  only  met  with  two  cases  of  acute  peritonitis  in 
which  no  local  cause  could  be  found.  The  pneumococcus  as  a  possible  cause  must  also 
be  remembered. 

t  I  fear  the  pathology  antl  the  published  cases  in  which  abdominal  section  have  been 
resorted  to  here  arc  alike  most  unfavourable.  If  the  surgeon  interfere  early,  he  will 
probably  only  find  a  congested  condition  of  the  peritoneum.  If  he  wait  till  tympanites 
and  purulent  effusion  be  present,  his  efforts  at  relief  will,  I  fear,  be  equally  futile  in 
the  face  of  this  severe  general  septic  infection. 


214  OPERATIONS  OX  THE  ABDOMEN. 

bottles  to  feet  and  tnuik.  A  hot  brandy  or  port  wine  enema  should  be 
given  immediateh^  before  the  operation,  and  saline  fluid  should  be 
injected  into  the  cellular  tissue  of  the  axillae  or  into  a  vein,  either  during 
the  operation  or  immediately  before  it  is  commenced.  In  the  worst 
cases  no  general  anaesthetic  should  be  given,  but  the  local  anesthesia 
of  cocaine  or  eucaine  made  use  of.  If,  however,  it  is  deemed  advisable 
to  induce  general  anaesthesia,  ether  or  the  A.C.E.  mixture  should  be 
used,  and  only  enough  given  to  keep  the  patient  quiet.  Thei*e  should 
be  a  plentiful  supplj^  of  hot  water  which  has  been  boiled,  and  care  must 
be  taken  that  no  instruments  or  towels  come  in  contact  with  the 
patient's  vitals,  either  cold,*  or  just  out  of  irritating  chemical  solutions. 

The  skin  having  been  well  cleansed,  the  abdomen  is  opened  by  a 
sufficiently  free  incision  in  the  middle  line.  Now,  and  throughout  the 
operation,  every  manipulation  is  to  be  carried  out  as  cjuickly  as  possible. 
Slow  operation  means  failure  (Lockwood).t 

When  the  peritongeum  is  opened  the  next  steps  will  depend  upon  the 
history  of  the  case,  and  the  fluid  or  gas  which  escape.  If  either  of  the 
latter  be  faecal,  the  ileo-caecal  region  is  first  examined,  owing  to  the 
frequenc}"  with  which  the  chief  causes  of  inflammatory  or  mechanical 
obstruction  are  foiTnd  here.  If  none  are  found,  and  the  cascum  is  dis- 
tended, it  is  clear  that  the  obstruction  is  in  the  large  intestine,  or  is 
inflammatory.  To  settle  this  point  the  sigmoid  flexure  is  next  examined. 
If  it  be  distended,  and  if  there  be  no  obstruction  in  the  rectum — a  point 
previousl}^  ascertained — the  case  is  clearly  not  one  of  mechanical  obstruc- 
tion (Lockwood).  The  odourless  gas  and  acid  fluid  mixed  with  recently 
taken  food  which  escapes  from  a  gastric  perforation,  the  brownish  acid 
fluid  (occasionally  fffical)  which  may  come  from  a  similar  lesion  in  the 
duodenum,  have  been  alluded  to  above.  Gelatinous-looking  fluid  pro- 
bably indicates  a  ruptured  cyst.  Bloody  ascitic  fluid  ordinarily  points 
to  haemorrhage  or  a  malignant  gro^^i;h. 

In  other  cases,  the  history,  the  age,  or  the  presence  of  enlai'ged 
mesenteric  glands  may  point  to  the  rupture  of  an  abscess  due  to  a 
caseating  gland,  or  a  rounded  body  in  the  pelvis  to  a  suppurating  ovarj-. 

We  will  next  suppose  a  perforation  closed,  or  some  other  cause 
removed,  and  now  we  have  before  us  how  best  to  deal  with  the  condi- 
tions remaining,  viz.,  the  distended  parah'sed  intestines,  the  removal 
of  the  septic  fluid,  and  the  question  of  drainage. 

I  have  already,  under  the  treatment  of  acute  intestinal  obstruction, 
dwelt  upon  the  necessity  of  emptying  the  intestines  before  the  abdomen 
is  closed;!  otherwise  death  is  almost  certain,  from  the  continued  toxaemia 

*  A  temperature  of  105°  will  be  sufficient  for  instruments,  towels,  &c.,  and,  as  I  have 
said  before,  if  any  viscus  has  to  be  withdrawn  outside  the  abdomen  it  should  be  the 
duty  of  one  assistant  to  keep  its  temperature  from  falling,  and  of  one  more  to  keep  him 
supplied  with  towels  or  tampons  previously  carboliscd  and  wrung  out  of  sufficiently 
hot  water. 

f  Med.-Chir.  Trans.,  vol.  xxviii.  Here  will  be  found  one  of  those  rare  cases  of  diffuse 
septic  peritonitis  saved  by  surgery.  The  cause  was  an  unexplained  perforation  of  the 
ileum. 

%  Travers,  as  Sir  F.  Treves  (Joe,  supra  cit.")  calls  him,  "  the  father  of  intestinal  surgery," 
long  ago  insisted  upon  the  need  of  this,  and  urged  that  if  the  intestines  were  distended 
the  operation  was  incomplete  without  this  step.  More  recently  Mr.  Greig  Smith  and 
Mr.  Lockwood  have  drawn  attention  to  the  need  of  this. 


ABDOMINAL  SECTIOX  IX  PEEITOXITIS.  215 

from  the  persisting  passage  of  organisms,  of  which  the  bacillus  coli 
communis  is  only  one,  and  from  the  interference  with  the  action  of  the 
lungs  and  heart  by  the  pushed-up  diaphragm. 

The  emptying  of  the  intestines  may  be  efiected  by  multiple  punctures, 
(this  being  only  safe  if  gas  alone  is  present),  with  a  fine  trocar,  such  as 
a  Southey's,  the  puncture  being  made  obliquely.  If  the  coats  are 
softened  and  the  puncture  is  not  effaced  by  some  of  them  gliding  over 
the  others,  a  drop  of  intestinal  contents  will  very  likely  ooze  out  and 
continue  to  leak.  This  spot  should  be  at  once  closed  by  a  suture,  with 
a  very  fine  round  needle,  otherwise  matters  will  only  be  made  worse. 
Where  fluids  are  also  present,  incising  one  or  two  of  the  most  distended 
coils  is  preferable  to  the  use  of  a  large  trocar,  which,  however  sharp,  is 
liable  to  leave  lacerated  edges.  The  incisions  should  be  about  three- 
quarters  of  an  inch  long  and  made  in  the  long  axis  of  the  bowel,  on  the 
aspect  opposite  to  the  mesentery.  As  I  have  before  said,  even  after 
boldly  incising,  the  amount  of  relief  secured  is  often  disappointing.  This 
is  due  in  part,  as  the  late  ]Mr.  Greig  Smith  pointed  out,  to  the  acute 
flexures  in  which  the  distended  intestines  are  held  by  the  mesentery,  in 
part,  also,  to  the  easily  paralysed  condition  of  the  bowel.  The  opening 
being  brought  well  outside,  and  safely  kept  there  by  an  assistant,  the 
surgeon,  partly  by  tracing  up  and  squeezing  adjacent  coils,  partly  by 
elevating  one  end  and  lowering  the  other  of  each  distended  loop,  aids 
the  evacuation.  As  each  coil  is  emptied  it  is  cleansed  and  returned, 
but  any  incised  loop  is  kept  outside  till  the  last,  then  closed  with 
Lembert's  sutures  and  dropped  back. 

Where  any  perforation  is  present  it  may  be  simply  enlarged  for 
drainage — a  plan  adopted  by  Mr.  Lockwood  in  his  successful  cases. 
Where  a  patch  is  gangrenous  and  there  is  no  time  for  resection,  a  Paul's 
tube  may  be  inserted — a  plan  adopted  in  a  case  of  acute  intestinal 
obstniction  due  to  bands,  with  great  distension  of  the  small  intestines, 
under  the  care  of  Dr.  Perry  at  Guy"s  Hospital,  in  1895.  The  lad  re- 
covered with  a  faecal  fistula,  which  was  subsequently  closed  (p.  278). 

The  next  step  is  the  cleansing  of  the  peritonseal  sac.  The  surgeon 
must  here  remember  the  distinction  (p.  213),  made  by  Mickulicz, 
between  a  septic  peritonitis,  alreadtj  diffuse  and  general,  or  one  shut  oj^ 
here  a/iul  there  hi/  adhesions,  andj  so  sprreading  more  sloa-ly.  In  the  cases 
v'here  the  peritonitis  tends  to  he  of  aplastic  character,  where  the  intestines 
are  matted  here  and  there  with  lymph  of  varying  tenacity,  other  parts  of 
the  peritonfeal  space  appearing  healthy,  the  surgeon  has  to  face  the 
follo^ang  dilemma.  If  he  separate  the  adhesions  he  will  set  up  trouble- 
some bleeding,  he  mav  break  down  important  repair,  and  he  may  infect 
peritonaeum  still  luicontaminated.  On  the  other  hand,  by  not  disturb- 
ing the  adhesions,  he  may  leave  pools  of  septic  fluid,  and  he  may  miss, 
just  when  it  is  within  his  reach,  the  chance  of  closing  some  perforation, 
or  of  removing  some  other  cause  of  all  the  trouble.  I  have  mentioned 
such  an  instance  at  p.  208,  in  the  treatment  of  perforated  gastric 
ulcer. 

Sir  F.  Trevess  authoritative  opinion  in  these  cases  inclines  (loc.  saprra 
cit. ;  Brit.  Med.  Journ.,  vol.  i.  1894,  p.  519)  to  '"doing  no  more  than  is 
necessary,  or  as  little  as  is  obvious.  A  clump  of  adherent  intestines 
will  often  cover  and  protect  a  pei-foration,  and  the  ubiquitous  lymph 
will  many  times   close  such  an  opening  with  more  -speed  and  security 


2l6  OPERATIONS  OX  THE  ABDOMEN. 

than  are  provided  by  any  system  of  sutiTring.*  ....  The  main  pm*pose 
of   the   operation  is  to  allow  a  noxious  exudation   to  escape,  and.  if 

possible,  to  free  the  peritonaeum  of  the  cause  of  its  trouble If 

the  operator  can  rid  the  serous  cavity  of  the  effects  of  the  perforation,  he 
ma}^  very  often  leave  the  breach  itself  to  be  dealt  with  by  natural  means." 

Sir  F.  Treves  goes  on  to  say  that  irrigation  is  certainly  not  suited 
to  this  class  of  case — peritonitis  partially  localised  by  adhesion — gauze 
sponges  forming  here  the  best  means  of  cleansing  the  peritonseum. 
Drainage  is  seldom  required,  and  when  employed  is  best  provided  for 
by  strips  of  iodoform  gauze  passed  among  the  coils  to  the  necessary 
depth.  The  same  authority  recommends,  in  this  form  of  perforation,  a 
lilieral  dusting  of  the  serous  membrane  with  iodoform,  save  in  the  case 
of  children. 

My  own  opinion  with  regard  to  these  cases  of  septic  peritonitis 
partially  localised  by  adhesion  is,  that  the  chief  point  is  drainage, 
especialh'  where  the  fluid  is  pui'ulent  and  fretid.  Drainage  must  here 
be  secured  at  all  hazards,  both  by  gauze  drains  and  tubes  from  in  front, 
and  by  incisions  behind.     Repeated  operations  may  be  required. 

It  is  in  cases  of  diffuse  sejdic  iieritonitU  that  the  qiiestion  of  the  best 
means  of  cleansing  the  i:»eriton0eal  sac  will  especially  arise.  There  is 
still  considerable  difference  of  opinion  on  this  point,  some  surgeons 
strongly  recommending  and  always  practising  irrigation,  whereas  others 
condemn  it  and  rely  entirely  on  sponging ;  others,  again,  make  use 
of  neither  {^cide  infra).  Even  la3ang  individual  opinion  on  one  side, 
it  is  no  easier  to  judge  from  results,  since  successful  cases  treated  by 
either  method  are  necessarily  few  and  far  Ijetween.  Moreover,  in  study- 
ing recoi-ded  cases  it  becomes  quite  evident  that  the  condition  described 
by  different  surgeons  under  the  heading  of  general  septic  peritonitis  is 
not  always  really  the  same. 

Again,  it  should  be  borne  in  mind  that  the  result  in  any  given  case 
depends  largely  upon  two  important  factors,  namely,  the  virulence  of 
the  infection  and  the  resisting  ])ower  of  the  individual,  neither  of  which 
can  be  in  any  way  gauged  by  the  a]3pearances  on  abdominal  section ;  so 
that,  on  the  one  hand,  in  a  case  of  infection  with  a  virulence  of  low 
type  in  a  patient  of  high  resisting  power,  either  irrigation  or  sponging 
may,  although  incomplete,  be  sufficient  to  turn  the  balance  in  the 
patient's  favour ;  on  the  other  hand,  a  very  virulent  infection  in  a 
patient  whose  resisting  power  is  small  will  be  certainly  fatal,  and  this 
result  \\W\  not  be  affected  in  the  least  by  either  irrigation  or  sponging. 
Finally,  it  must  be  borne  in  mind  that,  whichever  method  is  adopted, 
and  however  completely  it  is  apparently  carried  out,  anything  like  a 
bacteriologically  complete  cleansing  of  the  infected  surface  is  quite  out 
of  the  (juestion. 

Where  the  fluid  is  non-infective,  e.(].,  blood,  h}datid,  bile,  &c.,  where 
it  is  "recent  or  not  wides])read,  and  where  the  operation-area  can  be 
safely  circumscribed,  cleansing  of  the  peritona?al  sac  can  be  best  and 
most  safel}^  accom])lished  by  the  use  of  gauze  sponges,  either  iised  dry 
or  wrung  out  of  boiled  water  or  salt  solution. 

*  Sir  F.  Treves  refers  to  Kaiser's  statistics  QJJeufgrJi.  Arch.  f.  Idin.  Med.,  1876).  Here 
thirty  cases  of  operation  for  perforative  peritonitis  were  collected  with  eleven 
recoveries.     In  iive  of  these  the  exact  site  of  the  perforation  was  not  ascertained. 


ABDOMES'AL  SECTIOX  IX  PERITONITIS.  21/ 

Wliere.  however,  the  fluid  is  septic  and  widely  spread,  irrigation  with 
sterile  salt  solution  introduced  at  a  temperature  of  i  io°  F.  is  probably 
preferable.  In  Sir  F.  Treves's  words  this  should  be  •'  introduced  at  low 
pressure,  but  in  a  wide  stream.  The  irrigating  tube  is  of  soft  rubber, 
and  may  hare  a  diameter  of  three-quarters  of  an  inch.  The  tube  itself 
is  introduced  into  the  belly  cavity.  The  flow  through  it  can  be  regulated 
by  a  clip.  Any  form  of  rigid  nozzle  is  to  be  most  strongly  condemned. 
The  solution  should  flow  g*ently  into  the  abdomen.  The  peritonjeal  cavity 
is  to  be  flooded,  and  not  to  be  scoured  out  with  a  \*iolent  stream  of  water 
which  hisses  and  rushes  from  a  vulcanite  nozzle  like  a  miniature  fire- 
hose. When  the  belly  cavity  is  quite  fall  of  fluid,  the  surgeon's  hand, 
which  is  already  in  position,  is  moved  to  and  fro  amongst  the  intestines 
with  great  gentleness.  By  a  movement  of  the  hand,  and  pressure  here 
and  there,  the  fluid  overflows  from  the  wound,  and  is  replaced  by  the 
steady  stream.  As  the  water  which  escapes  becomes  clear,  the  upper 
end  of  the  table  is  raised  so  that  the  shoulders  are  much  elevated,  and 
then  little  has  to  be  done  but  to  wash  out  the  most  dependent  parts, 
including  especially  the  pelvis.*  Finally,  what  fluid  remains  in  the 
pelvis  is  removed  with  sponges,  and  a  sponge  on  a  holder  is  retained  in 
the  bottom  of  the  pelvis  during  the  introduction  of  the  stitches,  and 
only  withdra\\Ti  at  the  last  moment."  f  It  is  important  that  the  tem- 
perature be  constant,  the  abdomen  not  over-distended,  and  that  the 
stream  be  not  directed  against  the  diaphragTa.  K  these  precautions  be 
neglected  alarming  dyspnoea  may  take  place  (Reichel).  Polaillon  has 
noticed  three  cases  of  cessation  of  respiration  in  the  human  subject 
during  irrigation  (Treves).  The  most  suitable  fluids  are  the  saline 
infusion  already  advised,  or  boiled  water,  or  dilute  solutions  of  boric  or 
salicylic  acid,  or  of  iodine  about  3j- — Oiij-  Iii  order  to  render  the 
flushing  more  efficient  some  surgeons  allow  the  intestines  to  escape  into 
hot  moist  towels.  Mr.  M"Cosh  (Ann.  of  Surg.,  vol.  i.  1897,  p.  6S6). 
with  an  experience  of  forty-three  cases,  makes  a  practice  of  this,  except 
where  the  distension  is  enormous  and  the  hearts  action  very  weak.  He 
say  a  :  '"  Where  possible,  however,  even  at  a  great  risk,  the  intestines 
are  removed,  and  if  well  protected  by  hot  towels.  I  have  not  found  that 
this  evisceration  increases  to  any  extent  the  shock  of  the  operation." 
Dr.  Finney,  again,  who  reports  a  brilliant  group  of  five  successive  cases, 
all  of  which  were  cured  {Johiia  Hojjkiii,^  Hoi^p.  Bull..  July  1S97),  con- 
sidering the  usual  means  adopted  inadequate,  goes  even  further  than 
this,  and,  betbre  returning  the  intestines,  thoroughly  cleanses  each  loop 
with  gauze  wrung  out  of  hot  salt  solution,  using  "  considerable  force."' 
It  may  be  mentioned  that  Dr.  Finney  considers  thorough  wiping  with 
sponges  more  useful  than  flushing. 

Drainage. — Where  the  fluid  was  septic  this  should  be  employed. 
First  as  to  .nte.  As,  at  a  necropsy,  fluid  is  always  found  in  the  pelvis, 
and   sometimes    only  there,  a   glass    drainage-tube  should   always   be 


*  From  first  to  last  the  whole  peritonaeal  sac  and  its  contents  must  be  gone  over  as 
methodicallr  as  possible.  For  ensuring  this  the  excellent  directions  of  Dr.  ilaolaren, 
of  Carlisle  (p.  207).  should  be  remembered, 

t  There  are  some  who  hold  that  irrigation  fluid  may  safely  be  left  behind,  as  the 
peritoneum  has  well-known  powers  of  absorption,  Such  too  often  forget  that  here  we 
are  dealing  with  a  damaged  sac.  not  the  healthy  one  of  experimenters. 


21 8  OPERATIONS  OX  THE  ABDOMEN. 

placed  in  the  pelvis,'*  so  that  fluid  can  he  sucked  out.  Other  glass 
tubes,  or  india-rubber  ones  of  appropriate  size  and  properly  fenestrated, 
should  be  placed  in  those  areas  which  have  been  most  distm-bed  (Treves), 
or  where  especially  sej)tic  collections  were  found,  or  where  bleeding  may 
be  going  on.  These  must  be  brought  out  in  front,  or,  by  counter- 
puncture,  laterally  or  behind.  Provisional  sutures  must  always  be 
inserted.  The  tubes  may  usually  be  removed  in  forty-eight  hours.  If 
the  discharge  that  is  sucked  out  of  an}-  of  them  be  foul,  it  is  best  to 
trust  to  frequent  withdi-awing  of  the  fluid.  Irrigation  by  the  tube  may 
produce  fatal  collapse,  and  it  is  difticult  to  make  certain  of  the  return  of 
the  fluid  sent  in. 

Gauze  drains  are  made  of  strips  of  iodoform  gauze  about  one  inch  and 
a  half  wide  and  containing  five  or  six  layers. f  They  are  largely  used  by 
Continental  surgeons.!:  The  objection  to  this  form  of  drainage  is  the 
risk  of  poisoning,  the  difficulty  and  pain  in  removing  them,  and  the 
greatly  increased  risk  of  hernia.  As  it  is  certain,  however,  that  the 
necropsies  in  septic  peritonitis  show,  most  constantly,  inadequate  drain- 
age, I  am  of  opinion  that  the  above  means  of  drainage  should  be  much 
more  extensively  employed,  until  replaced  by  treatment  more  satisfac- 
tory. The  great  importance  of  drainage  in  these  cases  is  emphasised 
by  the  fact  that  of  ten  cases  of  generalised  septic  peritonitis  treated  by 
Dr.  Van  Arsdale  by  drainage  only,  recovery  took  place  in  eight  (Ann.  of 
Surg.,  vol.  ii.  1897,  P-  238).  Neither  flushing  nor  sponging  was  employed 
here,  but  simply  the  making  of  two  incisions  and  introducing  *'  large 
rubber  drainage-tubes  in  difierent  directions  through  the  openings,  and 
packing  with  iodoform  gauze." 

^\  here  the  peritomeal  surface  has  been  unavoidably  damaged,  as  in 
the  separation  of  adhesions,  the  treatment  must  vary  according  to  the 
severitj^  of  the  lesion.  In  slight  cases  iodoform  may  be  rubbed  in,  in 
severer  ones  an  omental  graft  employed,  or  tamponnading  with  iodoform 
gauze.  The  latter  is  the  most  generally  applicable,  and  that  with  the 
least  delay. 

After-treatment. — Two  points  only  will  be  referred  to  here.  They 
are  the  most  important.  One,  the  need  of  persevering  persistence  in 
combating  shock;  the  other,  the  value  of  aperients.  If  tympanites 
and  distension  supervene  or  continue,  the  paralysed,  thinned  intestinal 
walls  probaljly  allow  of  the  passage  through  of  bacteria  or  their  products, 
which  are  taken  up  from  the  peritoneal  sac,  thus  giving  rise  to  a  toxic 
state.      Tlie  passage  of  the  long  tube,  the  introduction  of  enemata  con- 

*  Sir  F.  Treves  writes  as  follows  on  this  point  :  •'  There  seems  little  to  commend  the 
employment  of  a  glass  tube  passed  into  the  fundus  of  Douglas's  pouch.  I  have  ceased 
to  use  this  appliance."  This  advice,  I  think,  though  it  is  not  so  stated,  should  refer 
only  to  cases  where  the  peritonteal  sac  has  been  thoroughly  dried,  or  where  the  degree 
of  sepsis  was  but  slight. 

f  Jalaguier  (^Bull.  dc  Mem.  de  la  Soc.  dc  Chir.,  1891,  p.  800)  is  quoted  by  Sir  F.  Treves 
as  having  passed  these  strands  in  all  directions  amongst  the  intestinal  coils  from  the 
diaphragm  to  the  pelvis  with  a  good  result. 

t  The  Mickulicz  drain  or  tampon  is  used  to  check  dangerous  abdominal  liEemorrhage, 
to  close  extensive  breaches  in  the  peritonaeum,  or  to  shut  off  structures  which  arc 
septic.  It  is  a  sheet  of  iodoform  gauze  placed  in  situ  as  an  open  bag,  and  stuffed  with 
strips  of  the  same  material.  These  are  removed  piece  by  piece  after  the  first  forty- 
eight  hours  ;  a  few  days  later,  when  empty,  the  bag  itself  is  removed. 


ABDOMINAL  SECTIOX  IX  PERITONITIS.  219 

taining  ol.  ricini  gij.,  ol.  terebinth.  §ss.,  or  mag.  sulph.  3ij.;  or,  if  the 
patient  can  swallow,  the  administration  of  calomel  gr.  ij.  every  two 
hours  may  be  very  useful.  Dr.  M'Cosh  (loc.  supra  cit.)  advocates  injec- 
tions of  magnesium  sulphate  into  the  intestine  at  the  close  of  the  opera- 
tion. He  makes  the  injection  into  the  small  intestine  as  high  up  as 
possible,  and  uses  a  saturated  solution  containing  between  one  and  two 
ounces  of  magnesium  sulphate,  the  needle  puncture  being  closed  with  a 
Lembert's  suture.  Where  the  bowel  has  been  emptied  by  incision  the 
above  may  not  be  required.  Finally,  by  the  firm  application  of  towel- 
pads  the  onset  of  tympanites  may  sometimes  be  prevented. 

B.  In  Tubercular  Peritonitis. 

Although  the  question  of  the  advantage  of  operation  in  this  disease 
has  been  much  debated,  there  can  now  be  little  doubt  that,  in  suitable 
cases,  great  benefit  has  often  resulted  from  operation.  It  is  still  very 
difficult  to  determine  the  actual  percentage  of  permanent  cures,  owing 
to  the  small  number  of  cases  that  have  been  efficiently  followed  up. 
Dr.  H.  P.  Hawkins  (St.  Thomas's  Hosp.  Rep.,  1892),  from  an  examina- 
tion of  100  cases  treated  consecutively  at  St.  Thomas's  Hospital,  came 
to  the  conclusion  that  there  is  but  little  difference  in  the  mortality 
whether  operation  is  resorted  to  or  not.  Such  slight  difference  as  does 
occur  is  in  favour  of  operation.  The  following  figures,  quoted  by  Mr. 
"Watson  Cheyne  (Lancet,  vol.  ii.  1899.  p.  1725).  are  distinctly  more 
favourable.  In  1895,  Roersch  published  358  cases  with  the  following- 
results.  The  deaths  immediately  due  to  the  operation  numbered  32, 
deaths  at  a  later  period  (within  eighteen  months)  and  due  to  extension 
of  the  disease,  general  tuberculosis,  &c.,  numbered  51.  In  the  rest  of 
the  cases  improvement  followed,  and  many  were  apparently  cured.  For 
instance,  in  53  cases  two  years  and  upwards  had  elapsed  since  the  opera- 
tion, and  the  patients  were  apparently  quite  cured.  According  to  these 
figures,  improvement  or  cure  therefore  results  in  75  per  cent,  of  the  cases 
operated  on.  As  pointed  out  by  Mr.  Watson  Cheyne,  this  percentage  is 
too  high,  since  many  cases  relapse  even  after  prolonged  periods  of  appa- 
rent cure,  and,  moreover,  the  successful  cases  are  more  likely  to  be 
published  than  the  failures. 

Mr.  '\^'atson  Cheyne,  as  a  result  of  his  own  valuable  experience,  con- 
siders that  improvement  takes  place  in  about  50  per  cent,  of  the  cases, 
and  he  states,  moreover,  that  in  many  the  rapid  improvement  after  opera- 
tion was  most  remarkable.  He  says  :  "I  must  confess  that  I  have  been 
surprised  at  the  recovery  of  some  of  these  cases.  On  opening  the 
abdomen  one  finds  tubercles  everywhere,  the  intestines  protrude  from 
the  wound  and  are  seen  to  be  red.  inflamed,  and  covered  with  tubercles, 
some  of  them  sometimes  of  considerable  size,  the  abdominal  cavity  feels 
like  a  bag  of  rice ;  and  yet  in  these  cases  recovery  may  follow.  In  two 
cases  in  which  I  made  a  very  bad  prognosis  after  the  operation,  on 
account  of  the  size  and  the  number  of  the  tubercles  scattered  all  over 
the  intestines  and  abdominal  cavity,  recovery  took  place  rapidly,  and 
apparently  completely."' 

From  the  point  of  view  of  surgical  interference  in  this  disease, 
the  following  classification  of  the  principal  types  of  the  affection  is 
important. 

A.  The  Ascitic. — Here  the  inflamed  peritonfeal  sac  and  its  contents 
are  studded,  as  far  as  can  be  seen,  with  hosts  of  gTey  "sago  grain" 


226  OPERATIONS  ON  THE  ABDOMEN. 

granulations,  tending  to  become  confluent.  Caseation  is  absent,  or  only 
present  in  a  very  early  stage.  The  fluid  is  rarely  sero-purulent.  Adhe- 
sions are  absent  or  insignificant.  The  fluid  here  may  be  localised  and 
encysted.  The  ascitic  form  may  come  on  very  insidiously,  and  is  not 
uncommonl}^  the  subject  of  a  mistake  in  diagnosis.  B.  The  Caseatinr/ 
(ind  Purulent. — Here  caseation  is  always  present ;  the  amount  of  pus 
varies.  Usuall}^  this  is  abundant,  and  is  too  often  encj^sted,  imperfectly, 
in  many  collections.  More  rarely  the  caseation  is  dry,  unattended  with 
effusion,  the  intestines  being  matted  together  by  adhesions  which  are 
themselves  infiltrated  and  caseating.  If  the  adhesions  are  separated, 
hosts  of  small  loculi  present  themselves,  with  scanty  fluid,  usualh" 
purulent.  The  caseating  is  the  ^'ariety  which  we  see  so  typically  in 
wasted  children  with  hectic,  vomiting,  and  diarrhoea.  C.  The  Fibrous. — 
This  is  the  rarest,  but  a  favourable  variet}^.  The  bacilli  are  probably 
few.  Caseation  is  absent,  and  any  fluid  present  serous  and  scanty.  In 
this  form  and  the  second,  if  such  parts  as  the  omentum  and  mesentery 
are  densely  infiltrated,  a  new  growth  may  be  closel}'  simulated. 

The  amount  of  improvement  after  operation  that  may  be  expected  in 
any  case  of  tuberculous  peritonitis  depends  chiefly  upon  two  considera- 
tions— (i)  the  stage  which  the  disease  has  reached,  and  (2)  the  type  of 
disease  that  is  present. 

(i)  The  Stage  of  the  Disease. — It  is  most  important  that  the  operation 
should  be  undertaken  before  the  vitality  of  the  patient  has  been  much 
diminished  by  general  failure  of  nutrition,  hectic,  or  tuberculous  disease 
of  other  parts,  &c.,  in  order  that  the  effect  of  the  operation  itself  may  be 
quickhT"  recovered  from.  For  in  the  advanced  stages  of  the  disease  the 
shock  alone  of  the  operation  may  be  sufiicient  to  bring  about  a  fatal 
result,  or  in  any  case  to  hasten  the  end.  Mr.  Watson  Cheyne's  advice 
(Joe.  sup-a  cit.)  on  this  point  may  be  quoted :  "I  should  say  that  in 
practically  all  cases  where  improvement  does  not  follow  under  medicinal 
treatment  after  a  reasonable  time,  say  in  from  four  to  six  weeks  in  acute 
cases  to  from  four  to  six  months  in  chronic  cases,  the  abdomen  should 
be  opened  whether  there  be  ascitic  fluid  or  not.  The  operation  may 
do  good  in  cases  where  it  is  least  expected  to  do  so,  and  it  is  but 
seldom  that  it  can  do  any  real  harm.  Do  not  in  any  case  allow  the 
patient  to  go  doM'nhill  too  much,  otherwise  one  cannot  expect  good 
results  to  follow,  and  it  is  fair  neither  to  the  patient  nor  to  the  surgeon." 

(2)  The  Type  of  Disease. — The  most  favourable  cases  are  those  be- 
longing to  Class  A,  where  there  is  free  fluid  and  the  adhesions  are  few. 
Class  C  is  also  favourable  for  operation,  but  Class  B  is  distinctly  un- 
favourable. Here  the  operation  may  do  much  harm,  for  adhesions  are 
numerous  and  the  wall  of  the  bowel  often  much  thinned.  The  result  of 
manipulation  is  frequently  the  production  of  one  or  more  f?ecal  fistulae, 
with  perhaps  the  setting  up  of  acute  suppuration.  Improvement  has, 
however,  resulted  even  in  some  of  these  cases,  for  Mr.  Watson  Che3^ne 
points  out  that  there  is  no  class  of  cases  in  which  some  improvement 
has  not  taken  place,  so  that  it  is  very  difficuit  to  absolutely  exclude 
any  case  from  operation. 

Operation. — In  the  majority  of  cases  this  consists  simply  in  opening 
the  abdominal  cavity  by  means  of  a  median  incision  and  letting  out  the 
fluid.  The  escape  of  the  fluid  may  be  facilitated  by  turning  the  patient 
on  to  his  side,  and  also  to  some  extent  by  sponging.    Where  the  fluid  is 


ENTEROSTOMY.  221 

loculated  by  means  of  adhesions,  the  separate  loculi  may  be  made  to 
communicate  by  gently  breaking  through  such  of  the  adhesions  as  may 
be  necessary  for  this  purpose.  No  extensive  disturbance  of  the  adhesions 
beyond  this  is  either  necessary  or  advisable.  There  is  nothing  to  be 
gained  by  either  washing  out  the  abdominal  cavity  or  by  drainage,  so 
that  as  soon  as  all  the  fluid  has  escaped  the  abdominal  wound  should  be 
closed  and  the  dressings  applied.  In  carrying  out  this  operation,  in 
some  cases  an  obvious  primary  seat,  such  as  a  tuberculous  Fallopian  tube 
or  caecum  or  appendix,  may  be  discovered.  This  may  be  removed  should 
the  condition  of  the  patient  be  such  as  to  admit  of  the  necessary  pro- 
longation of  the  operation,  and  if  the  adhesions  are  not  so  numerous  as 
to  render  the  procedure  very  difficult.  In  many  cases,  however,  in 
which  such  a  primar}"  focus  is  found,  it  will  be  flrmly  fixed  to  other 
important  structures  or  embedded  in  a  mass  of  adhesions  ;  in  such 
cases  the  wiser  course  will  generall}'  lie  in  making  no  attempt  at  a 
radical  operation,  but  in  resting  content  with  letting  out  the  ascitic 
fluid  as  described  above. 

If  on  opening  the  abdomen  the  case  is  found  to  belong  to  Class  B, 
great  care  and  gentleness  must  be  used  in  opening  up  and  dealing  with 
abscess  cavities,  for  the  walls  of  the  intestines  are  frequently  thinned  and 
softened  by  the  disease,  so  that  any  undue  roughness  in  handling  is 
extremely  liable  to  result  in  rupture  of  the  bowel,  either  at  the  time  or 
later,  causing  fsecal  abscess  or  fistula.  No  attempt  should  be  made  in 
such  cases  at  eradicating  the  disease,  but  abscess  cavities  may  be  treated 
as  tuberculous  collections  elsewhere  are  treated,  by  evacuating  the 
contents,  gently  swabbing  out  the  cavity  with  pledgets  of  sterilised 
gauze,  introducing  sterile  iodoform  emulsion,  and  then  closing  the 
cavity.  If  the  pvis  is,  however,  found  to  be  feeculent  owing  to  infection 
from  the  bowel,  the  abscess  must  be  either  drained  with  a  tube  or  stuffed 
lightly  with  tampons  of  iodoform  gauze. 


ENTEROSTOMY.  —  FORMATION    OF    AN"    ARTIFICIAL   ANUS 
IN    THE    SMALL    AND    LARGE    INTESTINE. 

This  subject  has,  in  part,  been  alread}^  considered  under  Colotom}^ ;  I 
now  allude  to  it  again  to  aid  m}^  readers  when  they  have  to  face  the 
following  indications  : 

A.  Chiefly  referring  to  the  Small  Intestine  and  Acute 

Intestinal  Obstruction.  —  Either  a  temporary  or  a  permanent 
opening  may  be  made.  Temporary  drainage  is  called  for  (i)  when  the 
surgeon  decides,  owing  to  the  patient's  condition,  not  to  perform  an 
ordinary  abdominal  section,  but  to  relieve  the.  distension  as  a  temporary 
measure  by  opening  the  bowel  above  the  obstruction ;  (2)  in  those 
cases  (already  referred  to,  p.  178)  in  which  distension  of  the  small 
intestine  is  considerable,  and  in  which  the  obstruction  has  been  success- 
fially  relieved. 

A  permanent  opening  ^vill  be  necessary  when  the  surgeon  cannot 
detect  the  site  of  obstruction,  or  where  he  finds  it,  but  cannot  remove 
it.  Under  these  circumstances  he  may  be  driven  to  open  the  small 
intestine.     The  opening  must  be  as  near  the  csecum  as  possible,  in 


222 


OPERATIONS  ON  THE  ABDOMEN. 


order  to  avoid  the  danger  of  death  from  inanition  which  would  be  caused 
hj  an  opening  high  up  in  the  small  intestine. 

Such  operations  are  only  palliative,  and  are  only  to  be  made  use  of 
when  the  adoption  of  other  and  more  desirable  courses  is  impossible,  or 
when  the  surgeon  feels  sure  he  can  open  the  small  intestine  low  down. 
It  has  been  urged  by  those  who  have  recommended  such  operations — 
e.g.,  Nelaton,  1840 — that  some  obstructions  relieve  themselves  if  a  tem- 
porary outlet  has  emptied  the  accumulation  above.  This  may  be  true  of  a 
very  small  number  of  cases — e.g.,  volvuli  which  have  not  gone  too  far,  and 
loops  which  are  incarcerated  rather  than  strangulated.  Another  point 
urged  in  favour  of  this  operation  is  that  it  involves  much  less  shock  and 
disturbance  of  the  abdominal  contents.     This  last  is  true.     But,  from 

Fig.  50. 


To  show  Greig  Smith's  method  of  performing  temporary  enterostomy. 
B,  Bowel.     M,  Mesentery.     T,  Rubber  tube.     P,  Peritonaeum,     i,  Strapping,  fixing 
dressing.      2,  Pin  holding  bowel  and  tubing  in  position,      x — x,  Enlarged  view  of 
plan  of  fixing  bowel  and  tube  by  pin  and  suture.     (Greig  Smith.) 


what  I  have  seen,  this  operation  usually  fails,  by  leaving  irrecoverable 
mischief  behind  in  the  very  cases  to  which  it  is  best  suited — viz.,  acute 
obstruction  where  the  lesion  cannot  be  found,  or  where  it  cannot  be 
dealt  with,  or  is  beyond  recovery.  Even  if  it  succeed  it  is  at  the  cost 
of  great  and  lasting  inconvenience.  Owing  to  the  liquid  state  of  the 
contents,  control  is  very  slight,  and  the  raw  and  eczematous  con- 
dition of  the  tissues  adjacent  to  the  opening  is  productive  of  great 
discomfort. 

Temporary  Drainage  of  the  Small  Intestine  (Figs.  50  and  51). — 
The  following  method,  in  which  rubber  tubing  is  used  to  carry  off  the 
contents  of  the  bowel,  was  described  by  the  late  Mr.  Greig  Smith  (Ahdom. 
Surg.,  p.  687),  and  will  be  found  to  be  easy,  rapid,  and  satisfactory.     It 


ENTEROSTOMY. 


is  described  as  follows : — "  Between  the  second  and  third  fingers  of  the 
assistant's  left  hand  and  the  same  fingers  of  his  right  hand,  held  back 
to  back,  a  V-shaped  piece  of  the  intestinal  border  is  compressed  and 
excluded.  On  the  free  border  of  this  fold  the  incision  is  made  large 
enough  to  admit  the  tubing.  If  the  bowel  is  properly  held  no  gas 
or  fluid  escapes.  With  fine  peritoneeal  catch-forceps  the  mucous  niem- 
brane  on  each  side  of  the  small  incision  is  grasped  and  pulled  out  a 
little  way,  and  the  tubing,  stretched  over  a  blunt  j^robe,  is  pushed 
throiigh  the  opening.  The  tubing  is  at  once  fixed  to  the  margin  of 
the  incision  by  a  safety-pin  or  two,  or  in  the  manner  shown  in  the 
diagram  (vide  Fig.  50).  If  it  fits  accurately  there  will  be  no  escape 
of  intestinal  contents  by  its  side.  The  fingers  of  the  assistant  are  now 
removed,  and  the  gases  and  fluids  permitted  to  escajie.    When  the  bowel 

Fig.  51. 


Ftecal  fistula.  The  parietal  and  intestinal  pei-iton<pi;ra  have  been 
united  by  a  continuous  suture  (Kocher).  This  figure  should  be 
contrasted  with  Fig.  52,  which  shows  an  artificial  anus.  Here 
there  is  no  pi'olapsus  and  no  spur,  this  opening  being  intended 
for  temporary  purposes. 

has  collapsed  the  loop  is  cleansed  and  returned  into  the  abdomen,  leav- 
ing outside  about  an  inch  of  bowel  containing  the  tubing.  The  tubing 
should  at  its  inner  extremity  clear  the  parietes,  but  need  go  no  further 
inside.  The  parietal  sutures  already  placed  are  now  tied,  all  save  one, 
which  is  to  be  tied  in  a  few  days  when  the  extended  loop  is  retm-ned.'' 

Instead  of  the  above  the  following  method  may  be  used.  The  abdo- 
minal incision  is  closed  with  the  exception  of  an  inch  and  a  half  at 
the  lower  part.  Here  the  parietal  peritongeum  is  first  united  to  the  skin 
by  a  few  points  of  suture.  The  loop  of  intestine  which  it  is  intended  to 
drain  is  then  carefully  attached  to  the  parietal  peritona?um  bj^  a  con- 
tinuous silk  suture,  picking  up  the  serous  and  muscular  coats  of  the 
bowel  on  the  one  hand,  and  the  parietal  peritonaeum  on  the  other, 
as  shown  in  Fig.  51.  The  sutured  edges  are  then  sealed  with  collodion. 
The  bowel  is  now  punctm'ed  by  a  trocar  and  cannula  which  have  been 
passed  through  a  piece  of  thin  india-rubber  sheeting,  the  contents  of  the 
bowel  being  allowed  either  to  pass  into  the  dressings  or  being  led  away 
to  a  suital)le  vessel  by  means  of  a  tube  attached  to  the  cannula. 

Formation  of  a  Permanent  Artificial  Anus  in  the  Middle  Line 
(Fig.  52). — The  contents  of  the  peritona?al  sac  having -been  shut  olF  by 


224 


OPERATIGXS  OX  THE  ABDOMEN. 


gauze  tampons  and  sponges,  the  surgeon  makes  an  artificial  anus  in  one 
of  the  following  ways  : — A  loop  of  intestine,  as  near  the  obstruction  as 
possible,  being  chosen  by  its  distension,  congestion,  &c.,  it  is  brought 
outside,  and  as  much  of  the  median  incision  as  is  feasible  is  safety  closed 
with  sutures.  Those  sutures  which  have  to  be  placed  nearest  the 
intestine  should  not  be  tied,  but  kept  clamped  with  Spencer  Wells's 
forceps,  so  that  the  surgeon  may  easily  draw  out  or  replace  some  of  the 
intestine  as  he  requires.  The  intestine  is  now  fixed  either  b}^  some 
form  of  rod  and  sutures,  or  by  sutures  alone.  In  either  case,  if  there  be 
time,  the  parietal  peritonaeum  may  be  sutured  here  and  there,  b}^  points 


Formation  of  an  artificial  anus. 
B,  Bowel  on  pi-oximal  side  of  spur.     B',  Bowel  below  spur.      T,    Eubber  tubing. 
Sp,  Spur  :  at  the  top  the  black  circular  si^ot  represents  a  section  of  the  supporting 
rod.    I,  Strapping.    2,  Gutta-percha  tissue.    3,  Absorbent  dressing.    (Greig  Smith.) 

of  fine  silk  passed  with  round  needles,  to  the  peritonfeal  coat  of  the 
intestine  so  as  to  shut  off  the  general  peritonseal  sac,  great  care  being 
taken  not  to  perforate  the  lumen  of  the  bowel.  Then  a  piece  of  suitable 
bougie,  glass  rod,  &c.,  which  has  been  boiled,  is  passed  through  the 
mesentery,  avoiding  any  vessels,  so  as  to  keep  the  loop  well  out  of  the 
abdomen.  If  too  much  bowel  has  been  withdrawn  some  is  now  returned, 
the  parietal  wound  closely  sutured  up  to  the  projecting  gut,  and  a  few 
sutures  placed  between  the  intestine  and  the  margin  of  the  wound. 
These  must  not  enter  the  lumen  of  the  bowel.  Finally,  there  must  be 
no  twisting  of  the  gut  as  it  is  brought  out.  If  the  rod  is  used,  care 
miTst  be  taken  that  too  much  of  the  gut  is  not  prolapsed,  a  point  rather 
difficult  to  secure  by  this  method.  The  smaller  the  prolapsus  consistent 
with  safety — i.e.,  non-contamination  of  the  peritonaeal  sac — the  less  the 
irritation  and  bleeding  from  friction  of  the  clothes,  &c,,  in  the  future, 


ENTEROSTOMY.  225 

and  the  smaller  the  opening-  to  be  closed  by  any  subsequent  operation  if 
this  prove  feasible.  If  sutures  alone  are  used,  most  of  the  above  steps 
are  the  same,  but  extra  care  must  be  taken  in  closing  the  parietal  wound, 
so  as  to  support  the  intestine  which  is  to  form  the  artificial  anus,  and 
additional  sutures  must  be  passed  between  the  edges  of  the  wound  in 
the  parietes  and  the  bowel.  If  this  be  distended  much  caution  will  be 
required  lest  the  lumen  is  opened  and  the  wound  infected.  The  employ- 
ment of  the  continuous  suture  is  shown  in  Fig.  53. 

Opening  the  Bowel. — If  it  be  possible  a  few  hours  should  be  allowed 
to  elapse.*  But  if  immediate  relief  is  required  one  of  the  following 
methods  may  be  adopted.  The  whole  of  the  wound,  save  where  the 
opening  is  to  be  made,  is  covered  with  iodoform,  and  the  sutured  edges 
may  be  sealed  with  collodion  and  iodoform,  (i)  The  bowel  may  be 
opened  by  a  trocar  and  cannula  which  have  been  passed  through  a  piece 

Fig.  53. 


Formation  of  an  artificial  auus.  A  coutinuous  suture  has  been  used 
(Koclier).  It  is  evident  that  there  will  be  a  good  spur  and  plenty  of 
prolapsus;  much  of  this  will  be  cut  away  later  on.  This,  which 
is  intended  for  a  permanent  opening,  should  be  contrasted  with 
Fig.  51,  which  shows  a  ftecal  fistula  only. 

of  thin  india-rubber  sheeting  (Cripps)  so  that  the  iluid  fceces  do  not 
flood  the  wound,  &c.  A  very  useful  precaution  is  to  insert  a  temporary 
suture  into  the  intestine,  close  to  where  the  opening  is  to  be  made,  so 
that  by  pulling  on  this  the  surgeon  can  keep  the  bowel  forwards  and 
the  flow  away  from  the  wound.  (2)  If  the  trocar  and  cannula  are  not 
forthcoming,  the  patient  having  been  brought  to  the  edge  of  the  table 
and  partly  turned  on  to  one  side,  the  wound  is  protected  with  the  above 
precautions,  and  the  intestine  opened  by  a  small  incision,  the  faeces  as 
they  escape  being  quickly  washed  away  from  the  wound  by  a  gentle 
stream  of  boiled  water.  (3)  A  piece  of  rubber  drainage-tube  may  be 
inserted  into  the  bowel,  as  described  above  in  Greig  Smith's  operation 
for  making  a  temporary  fistula  {cide  Fig.  52).     (4)  A  fourth  method 

*  If  this  delay  is  possible,  a  guiding-stitch  should  be  inserted  (not  entering  the 
lumen  of  the  bowel)  at  the  point  where  the  opening  will  be  made.  This  renders  easy 
what  otherwise,  owing  to  the  rapid  alterations  in  the  surface  of  the  bowel  and  land- 
jnarks,  may  prove  very  difBcult. 

VOL,    II.  15 


226  OPERATIONS  OX  THE  ABDOMEX. 

is  to  make  use  of  a  Paul's  tube  (Fig.  54).     I  have  alreadj^  referred  to 
the  use  of  the  larger  size  in  the  performance  of  colotomy  (p.  106). 

The  glass  tubes  are  made  in  two  sizes.  That  used  for  the  colon 
or  rectum  (Fig.  54,  i)  has  been  improved  in  shape  by  Messrs, 
Wright  &  Co.,  of  New  Bond  Street,  who  have  succeeded  in  bending 
it  at  the  proper  angle,  which  avoids  all  strain  on  the  bowel.  It 
measures  5  inches  in  length  by  I  in  diameter,  has  a  double  rim  at  the 
bowel  end  and  a  single  rim  at  the  distal  end,  and  is  bent  at  a  right 
angle.  The  tube  for  the  small  intestine  (Fig.  54,  2)  is  as  light  as  is 
consistent  with  sufficient  strength.  It  measures  2^  inches  by  ^  inch, 
and  is  bent  at  a  right  angle  at  the  distal  end.  In  either  case,  the  end 
with  the  double  rim  is  introduced  into  a  small 
Fig.  54.  incision  made  in  a  loop  of  intestine,  drawn  out 

^^  if  possible,  and  safely  shut  off  with  aseptic  gauze 

y^^^  ,-„-Yp^  packing.  The  end  thus  inserted  is  then  securely 
i  .^^sg^Jig./  tied  in  with  a  silk  ligature  of  sufficient  stoutness. 
f  ;^^  ^^^^^^  While  this  is  being  tied,  an  assistant  with  twa 
I    ill  ^  F'^^    pairs  of  dissecting-forceps  should  keep  the  edges 

f  of  the  opening  in  the  bowel  well  pulled  up  over 
I  2  the  rim  of  the  tube.  Faeces  from  the  large  tube 
I  are  received  into  a  jaconet  bag  containing  wood- 
W  wool,  or  other  absorbent  material,  except  the  first 
^  rush  in  cases  of  obstruction,  which  is  best  re- 
ceived into  a  basin.  To  the  small  one  an  india- 
rubber  tube  is  attached,  which  conveys  the  liquid  fgeces  of  the  small 
intestine  into  a  bottle,  beneath  an  antiseptic  fluid  (Paul,  Liverpool 
Med.-Chir.  Journ.,  July  1892).  Two  objections  have  been  made  to  the 
use  of  these  tubes.  One,  that  it  is  difficult  to  insert  the  tube  without 
the  risk  of  letting  some  feeces  escape  over  the  wound.  This  is  certainly 
true  when  the  intestine  is  distended  and  the  fteces  fluid.  If,  however, 
the  loop  to  be  opened  is  emptied  into  adjacent  bowel,  and  temporarily 
clamped  if  possible,  the  introduction  of  the  tube  is  greatly  simplified ;. 
otherwise,  the  operator  may  safely  trust  to  drawing  out  the  bowel 
as  much  as  possible  and  isolating  it  with  gauze.  The  other  objec- 
tion is  that  the  silk  ligature  may  cut  its  way  through  too  quickh', 
especially  if  the  bowel  is  much  congested.  Thus,  the  tube  may  be  loose 
in  two  or  three  days  ;  but  it  not  infrequently  remains  for  a  week  firmly 
adherent,  partly  because  some  of  the  circulation  becomes  re-established 
beyond  the  ligature,  and  partly  owing  to  the  copious  exudation  of 
lymph,  which  covers  the  bowel  to  the  vqvj  end,  quite  concealing  the 
ligature  (Paul).  The  use  of  a  purse-string  suture  to  fix  the  tube  in  the 
bowel,  and  the  prevention  of  imdue  tightness  in  tying  in  the  tube,  will 
help  to  lessen  this  trouble.  If  the  tube  becomes  loose  too  soon,  two 
or  three  Spencer  Wells's  forceps  should  be  applied  to  the  margins  of 
the  opening  in  the  bowel,  so  as  to  keep  this  forward  until  the  parts 
are  more  firmly  healed. 

I  have  given  (p.  278)  an  instance  in  -n-hich,  in  1895,  after  dividing  two  bands  in  a  case 
of  acute  intestinal  obstruction  admitted  on  the  fourth  day,  I  drained  the  intestines  by 
a  Paul's  tube  tied  into  the  worst  of  three  gangrenous  patches  present.  Vomiting  with 
some  tympanites  continuing,  I  had  an  ounce  of  castor  oil  given  by  the  tube.  Abundant 
flatus  was  soon  passed  per  rectum,  and  recovery  steadily  followed.  Owing  to  the- 
patient's  brutish  behaviour — he  was  discovered  on  the  point  of  drinking  his  urine,. 


UNIOiN   OF  DIVIDED  OE  INJURED  INTESTINE.  22/ 

he  took  solid  food  from  other  patients,  and  five  days  after  the  operation  pulled  the 
tube  out  of  the  bowel — a  faecal  fistula  followed,  which  I  closed  by  the  method  given 
at  p.  278. 

Nelaton's  Operation.     Right  Iliac  or  Inguinal  Enterostomy. 

Operation. — A  horizontal  incision,  about  two  inches  long,  is  made  a 
little  below  the  centre  of  a  line  drawn  from  the  umbilicus  to  the  right 
anterior  iliac  spine,  or  one  lower  down  parallel  with  the  outer  part  of 
Poupart's  ligament.  The  ceecum  having  been  made  out  to  be  empty, 
the  relation  of  this  to  the  distended  coils  which  are  present  in  the 
wound  should,  if  feasible,  be  made  out,  so  that  the  small  intestine  may 
be  opened  as  low  down  as  possible.  In  making  the  opening  those 
details  already  fully  given  (p.  225)  must  be  followed. 

B.  Conditions  chiefly  affecting  the  large  Intestine 
and  bringing  about    Chronic   Intestinal  Obstruction.— 

Enterostomy  under  these  conditions  has  been  already  referred  to  in 
the  account  of  colotomy. 

Given  a  case  in  which  the  obstruction  is  somewhere  in  the  large 
intestine,  where,  though  perhaps  the  onset  has  been  given  as  acute,  the 
surgeon  is  clear,  from  the  age,  history,  &c.,  that  it  is  really  a  case  of 
acute  on  chronic  mischief,  the  following  course  should  be  followed. 

An  incision  being  made  below  the  umbilicus,  the  surgeon  examines 
first  the  sigmoid  and  then  the  large  intestine  up  to  the  ctecum.  The 
obstruction  having  been  found,  the  surgeon  must  deal  with  it  according 
to  the  patient's  condition  and  his  own  surroundings.  Many  will  prefer 
to  close  the  median  incision  and  perform  a  lumbar  colotomy  on  the 
right  or  left  side,  according  to  the  position  of  the  obstruction.  Others 
will  bring,  if  possible,  the  c^cum  or  sigmoid  or  transverse  colon  into 
the  median  incision  and  establish  the  artificial  anus  there.  I  have 
stated  at  p.  91  my  objections  to  thus  drawing  a  piece  of  rather  fixed 
large  intestine  up  into  the  middle  line.  For  my  own  part,  having  made 
out  the  obstruction,  I  should  prefer  to  deal  with  it  as  follows,  mention- 
ing only  the  more  iisual  sites  (footnote,  p.  92).  If,  as  is  most 
frequent,  it  is  in  the  sigmoid,  I  should  close  the  median  incision,  and 
bring  out  the  sigmoid  with  the  obstruction,  and  keep  the  loop  outside 
with  a  rod  and  sutures  (p.  104),  and  open  it  at  once  or  a  little  later. 
This  would  give  the  opportunity  of  resecting  the  affected  loop  later  on. 
Another  course  would  be  to  close  the  median  incision  and  perform  a 
left  lumbar  colotomy.  If  the  obstruction  was  in  the  splenic  flexure  I 
should  try  to  bring  the  transverse  colon  out  into  the  top  of  the  median 
incision  prolonged  upwards,  and  open  this  intestine  (p.  1 12).  If  the 
disease  is  in  the  hepatic  flexure,  a  right  lumbar  colotomy  would  be 
indicated,  the  median  wound  being  closed.  If  lower  down,  the  cascum 
must  be  opened.  I  have  pointed  out  at  p.  in  the  chief  objection  to 
this  step,  viz.,  the  liquid  character  of  the  escaping  fjBces. 

Operation. — Wherever  the  opening  is  made,  the  details  already  so 
fully  given  at  pp.  94  and  103  will  suffice. 

UNION    OF    DIVIDED     OR    INJURED    INTESTINE    BY 
SUTURE     OR    OTHERWISE. 

By  Suture. — The  methods  devised  are  very  numerous  ;  most  have 
quickly  become  obsolete.     I  shall  only  refer  to  four  here,  as  those  with 


228 


OPERATIONS  OX  THE  ABDOMEN. 


which  T  am  personally  acquainted,  and  those  which  will  be  found,  on 
the  whole,  the  simplest  and  the  most  efficient.  And  first  as  to  the 
essentials  of  a  good  intestinal  suture.     The  chief  are — 

(i)  It  must  be  simple  ;  one  that  can  be  rapidly  introduced,  and  one 
which  will  effectually  close  the  wound,  and  hold  it  secure  until  the 
parts  are  firmly  healed.  (2)  In  its  introduction  attention  must  be  paid 
to  the  following  :  (a)  The  sutures,  when  applied  from  and  knotted  out- 
side, must  not  pass  through  the  mucous  coat,  otherwise  they  maj''  draw 
septic  fluids  from  within  the  bowel  to  the  peritonseal  surface.  Q))  Each 
suture  should  pass  down  to,  and,  if  possible,  take  up  a  little  of,  the  sub- 
mucous coat,  which  is  relatively  strong  and  thick  (Fig.  57).  In  any  case, 
each  suture  must  take  a  sufficiently  firm  hold,  so  as  not  to  cut  out  when 
any  strain  is  put  upon  it,  e.<j.,  by  peristalsis  or  distension,  (c)  Attention 
must   be  paid  to  the  risk   of  sloughing  along  the  edges  if  too  many 


Fig.  55. 


Fig.  55. 


Lenibert's  suture,  as  used 
by  Sir  W.  Mac  Cormac  in 
two  successful  cases  of  intra- 
peritonteal  rupture  of  the 
Ijladder. 


To  the  left  the  continuous  suture  is  shown. 
The  right-baud  figure  shows  the  continuous 
one  inverted  and  buried  by  a  row  of  Halsted's 
sutures.     (.Jessett.) 


sutures  be  used,  or  if  they  be  tied  with  strangling  tightness.  (<])  The 
material  used  must  be  unirritating  and  sufficiently  durable.  Fine 
Chinese-twist  silk,  thoroughly  sterilised  by  boiling  and  preservation  in 
carbolic  acid  lotion  (i  in  20),  is  the  best  material.  The  sutures  are  best 
introduced  by  the  ordinaiy  fine  round  sewing-needle,  the  aperture  of 
which  is  at  once  plugged  by  the  thread  which  follows,  while  its  round 
shaft  does  not  wound  small  vessels  like  the  ordinar}^  triangular-pointed 
needle,  which  is  not  needed  here  owing  to  the  readiness  with  which  the 
intestinal  coats  are  penetrated.  Fine  curved  needles  must  be  used  to 
introduce  the  sutures  from  within  (Fig.  132).  It  will  save  much  time 
to  have  many  needles  threaded  and  secured  on  lint  in  carbolic  acid 
lotion.  If  possible,  as  many  should  be  threaded  as  there  will  be  sutures, 
both  continuous  and  interrupted.     These  should  be  kept  apart. 

Chief  Varieties  of  Suture. —  (i)  The  Continuous  Suture  (Fig.  56,  a). 
— This  has  the  advantage  of  being  xqvy  quickly  applied.  If  the  points  of 
entrance  and  exit  be  at  some  little  distance  from  the  margins  of  the 
wound,  the  serous  surface  will  be  distinctly  inverted,  and  well  apposed. 


UNION  OF  DIVIDED  OR  INJURED  INTESTINE. 


229 


The  objections  to  it  are  mainly  three,  (a)  If  one  part  of  it  becomes 
loose,  the  whole  is  liable  to  become  insecm-e.  (ft)  It  is  difficult  in 
tightening  it  to  secm'e  even  tension  all  along  the  line,  (c)  If  the  bowel 
contract,  the  whole  suture  may  become  loosened,  and  the  wound  gape. 
Thus  this  suture  is  not  to  be  trusted  to  by  itself,  but  when  used  in 
combination  with  Lenibert's  it  is  most  valuable. 

(ii)  Lembert's  Suture  (Figs.  55  and  58). — The  value  of  this 
depends  on  the  fact  that  it  fulfils  in  an  eminent  degree  the  condition 
first  pointed  out  by  the  introducer,  that  to  obtain  union  of  an  intestinal 
wound  it  is  absolutel}'  needful  to  bring  and  keep  the  serous  surfaces  in 
contact.  Ii]ach  suture  should  be  inserted  not  less  than  one-third  of  an 
inch  from  the  cut  edge,  and  run  along  deeply  in  the  muscular  or  in  the 
sub-mucous  coat ;  it  is  then  made  to  emerge  just  wide  of  one  cut  edge, 

Fig.  57. 


PERITONEUM 

LOW  Cr  y.oscLt 

CI'i.CUl.AFl      >1  1 
SU3MUC0SA. 

MUSCULARIS 
MUCOUS 


Diagram  to  show  good  and  bad  methods  of  iusertiug  sutures. 

A.  Bad  method.     Suture  holds  only  muscle,  and  is  liable  to  cut  out. 

B.  Xot  good  method  ;    too  little  hold  of  submucosa,  and  too  sloping. 

C.  Proper  method;  takes  a  good  hold  of  the  tough  submucosa.     (Greig  Smith.) 


reinserted  just  beyond  the  opposite  edge,  then  at  once  made  to  travel 
between  the  coats  and  to  emerge  as  before. 

(iii)  The  Czerny-Lembert  Suture. — This  is  only  Lembert's  suture 
reinforced  by  a  deep  row  in  order  to  bring  together  accurately  the 
margins  of  the  mucous  membrane,  as  well  as  to  approximate  more 
perfectly  the  serous  surfaces.  The  introduction  of  the  first  or  deep  row 
is  shown  in  Fig.  132,  It  will  be  seen  there  that  these  sutures  are 
knotted  within  the  lumen  of  the  bowel,  but  it  is  better  to  make  them  in 
the  opposite  direction  and  tie  them  on  the  outside. 

(iv)  Halsted's  Quilt  or  Mattress  Suture  (Fig.  56,  h). — The  distin- 
guished surgeon  who  introduced  this  method  claims  for  it  that  (l)  it  is 
so  safe  that  a  single  row  of  it  will  sujffice ;  (2)  it  constricts  the  tissues 
less  than  Lembert's  sutures  :  (3)  it  tears  out  less  readily  if  submitted  to 
tension. 


230 


OPERATIONS  OX  THE  ABDOMEN. 


The  plan  adopted  by  most  surgeons  at  the  present  day  is  to  make  use 
of  a  double  line  of  suture — an  inner  continuous  one,  taking  up  all  the 
coats  of  the  bowel ;  and  an  outer  row,  consisting  either  of  a  second  con- 


FlG 


Suture  of  resected  intestine.  (Greig  Smith.)  Two  sheathed  Makins'  clamps 
are  in  position.  The  mesentery  has  been  divided  close  to  the  intestine  Its  cut 
edge  is  drawn  together  bj'  a  purse-string  stitch  :  this  leaves  free  small  flaps  of 
peritonasum,  which  can  be  grafted  on  to  the  base  of  the  line  of  union.*  Four 
sutures  are  inserted  into  the  opposite  sides  of  the  resected  gut,  and  careful  traction 
made  on  them  by  an  assistant.  This  raises  a  well-defined  fold  along  the  edge  of 
the  gut,  which  makes  the  insertion  of  sutures  more  easy  and  regular. 

tinuous  suture,  Lembert's  sutures,  or  Halsted's  sutures,  but  in  all  cases 
taking  up  only  serous  and  muscular  tissues,  and  thus  bringing  the 
serous  surfaces  into  apposition.  Which  of  these  will  be  finally  judged 
to  be  the  most  perfect  method  must  at  present  remain  uncertain. 


Other  methods  of  dealing  with  the  mesentery  are  given  at  p.  264,  Figs.  96,  97 


UXIOX  OF  DIVIDED  OR  INJURED  INTESTINE. 


231 


In  performing  the  operation  the  following  points  require  especial 
attention:  (i)  The  sutures  should  be  inserted  about  one-eighth  of  an 
inch  from  each  other.  (2)  Adequate  inversion  of  the  edges  and  contact 
of  the  serous  surfaces  must  be  secured,  this  being  effected  by  entering 
the  sutures  at  a  sufficient  distance  from  the  edges  (in  Fig.  58  this  is  not 
enough),  and  by  an  assistant  aiding  the  inversion  by  dipping  in  the 
surfaces,  just  before  each  batch  of  sutures  is  tied,  with  a  probe. 
(3)  Much  confusion  and  entanglement  will  be  saved  if  the  sutures  are 
tied  in  batches  of  four  or  six,  and  cut  short.  (4)  Each  needle  should 
■carry  only  enough  silk  for  one  or  at  most  two  sutures,  otherwise  there  is 
much  coiling  and  catching  about,  perhaps  on  surfaces  not  aseptic,  of  a 
long  thread.  The  mesentery  having  been  tied  off  up  to  the  level  of  the 
portions  of  bowel  to  be  united,  and  the  growth  or  gangrenous  intes- 
tine having  been  cut  away,  the  process  of  suturing  is  carried  out  as 
follows :  Two  fixation  quilt  sutures  are  first  passed  through  the 
serous  and  muscular  coats  at  the 

mesenteric    border    and    at    the  Fig-  59- 

opposite  edge.     These  are    held,  /! 

as     shown     in    the     figure     (58).     in         Division  of  mesentery  as  if i} 

catch  forceps,  and,  being  kept  taut       app™^^''*^  the  intestine.  /  -j 

by  an  assistant,  serve  to  ensure 

.1  .  ...  r.  Triangular  space  filled  with  - 

the  accurate  apposition  ot  corre-       fat.connectivetissue.ves- 

-..  .     ^  '■       ,^,  .  sels  and  nerves. 

spondmg  points.     1  he  continuous     „      ..v  .■     ,  .      .  fi^-^. -^"efy 

^  oX  Base  of  the  tnansle  formed » 

suture  is  then  introduced,  taking        tLintesT^e*'.'^'"'  *"'^*  °^ 

up    all   the    coats    of  the   bowel 

close  to  the  cut  edge,  in  the  fol-     perouscoat 

.  X  Muscular  coat J,'  ^| 

lowing  manner.      It  commences     mucous  membrane 

at    the    mesenteric    border,    and 
for  the  first  half  of  the  circum- 
ference of  the   bowel   is    passed  * 
from  within,  the  mucous  surface 
being    punctured    first   by    each 

stitch.    When  the  fixation  suture  S^^.,.^^  ^^^^^^^^  .^.^^^^ 

at  the  opposite  border  is  reached,  (Mac  Cormac.) 

the    order   is    reversed,    so   that 

the  second  half  is  passed  from  without,  the  serous  surface  being 
now  punctured  first.  Finally,  the  two  ends  of  the  suture  are  tied 
together  at  the  mesenteric  border. 

The  second  row  of  sutures  are  now  placed,  taking  up  serous  and 
muscular  tissues  only  and  inverting  the  first  line  of  suture.  Lastly,  the 
fixation  sutures  are  tied,  and  any  points  of  apparent  weakness  or 
insufficient  inversion  reinforced  by  further  sutures. 

However  circular  enterorra])hy  be  employed,  close  attention  must  be 
paid  to  these  points  shown  in  Fig.  59.  The  first  is  the  triangular 
space  which  is  formed  by  the  divergence  of  the  two  layers  of  the  mesen- 
tery at  their  junction  with  the  bowel.  This  is  occupied  by  fat,  connective 
tissues,  vessels,  and  neives.  In  the  suturing  of  resected  intestine  this 
space  must  be  obliterated  by  sutures  passing  from  intestine  to  mesentery 
(Figs.  97  and  99J.  The  thickness  of  the  bowel  is  also  to  be  noted. 
The  muscular  layer  is  (Fig.  59)  comparatively  thick,  and  sutures  here 
are  easy  of  introduction.  In  the  ileum  this  coat  would  be  much 
thinner  and  the  whole  tube  smaller. 


232  OPERATIONS  OX  THE  ABDOMEX. 

The  advantages  and  disadvantages  of  circular  enterorraphy  are  giveri 
at  p.  253,  where  this  method  of  uniting  intestine  is  compared  with  other 
means,  such  as  Murphy's  button,  Paul's  decalcified  bone  tubes,  Mayo 
iiobson's  bone  bobbins. 

Rogers'  Method  of  performing  Enterectomy  without  the  Aid 
of  any  Special  Apparatus. — At  the  j^resent  time,  while  the  best 
means  of  performing  enterectomy  are  still  .fuh  judice.  and  as  it  will  cer- 
tainly have  to  be  performed,  under  widely  different  conditions,  in  very 
different  wa3^s,  the  following  deserves  mention.  It  will  be  found' 
described,  Bi'it.  Med.  Journ.,  1896,  vol.  i.  p.  903.  The  method  consists 
in  turning  back  the  peritonjeal  coat  of  one  end  of  the  small  intestine, 
suturing  the  musciilar  coat  thus  exposed  to  the  peritonasal  coat  of  the 
other  end  of  the  intestine,  subsequently  turning  down  the  reflected 
portion  of  peritongeum  over  the  first  row  of  sutures,  which  are  thus 
completely  buried,  and  suturing  the  deep  surface  of  the  reflected  peri^ 
ton^eum  to  the  unreflected  serous  surface  on  the  other  end  of  the" 
intestine.  Thus  a  double  sero-fibrous  union  is  obtained  which  will 
unite  both  quickl}^  and  firmly.  The  inner  sutures  are  passed  throtigli 
the  muscular  coat  of  one  end  and  the  muscular  and  peritona;al  coats  of 
the  other  end  of  the  bowel,  while  the  outer  sutures  include  the  peri« 
tonseal  coats  only.  Each  row  of  sutures  is  a  continuous  one.  The 
second  one,  which  unites  the  peritoneeum  reflected  off  one  end  of  the 
bowel  over  the  same  coat  unreflected  on  the  other,  begins  by  uniting 
the  triangular  gap  at  the  mesenteric  junction  (a  most  important  spot, 
p.  231,  Fig.  59),  and  then  travels  round  the  bowel. 

The  following  advantages  are  claimed  by  Dr.  Rogers  for  this  method : 
(i)  It  can  be  done  with  the  aid  of  the  instruments  in  a  pocket-case, 
ordinary  round  sewing-needles  being  used  (although  curved  intestinal 
needles  are  to  be  preferred),  and  with  very  little  assistance,  and  is 
therefore  likely  to  be  of  especial  service  in  military  surgery  or  in  country 
or  foreign  practice.  Yet  (2)  it  can  be  completed  in  aboiit  half  an  hour, 
or  only  a  little  longer  than  the  time  required  with  the  aid  of  such  special 
appliances  as  plates,  buttons,  and  bobbins.  (3)  The  junction  is  a 
double  sero-fibrous  one,  and  hence,  as  the  late  Mr.  Greig  Smith  believed 
{Joe.  infra  cit.),  will  combine  the  maximum  of  rapidity  and  firmness, 
(4)  The  mesenteric  junction  can  be  made  very  firm  by  the  apposition  of 
the  muscular  coat  of  one  end  to  the  peritonaeum  of  the  other,  and  subse- 
quent covering  up  of  this  suture  by  the  reflected  peritonseum. 

The  chief  disadvantage,  on  the  other  hand,  lies  in  the  difficulty  in 
reflecting  the  peritonseal  coat.  The  late  Mr.  Greig  Smith  said  :  "  This  is 
not  easy  to  do ;  it  takes  some  time,  and  causes  bleeding  which  is  long  in 
stopping.    Also  it  often  causes  the  wounding  of  important  blood-vessels. ' 

Another  method  somewhat  similar  to  the  above  is  Morisani's  (Ce'uiralh. 
fiir  CJiir.,  1899,  vol.  xxxii.).  This  consists  in  removing  a  strip  of  mucous 
membrane  from  4-6  cm.  wide  from  the  distal  end  of  the  divided  bowel. 
The  proximal  end  is  then  invaginated,  its  serous  surface  thus  being 
brought  into  contact  with  the  denuded  area  of  the  lower  segment.  The 
two  ends  are  held  b}^  two  or  three  fixation  sutures  and  union  com- 
pleted by  means  of  a  continuous  siiture  piercing  the  whole  thickness  of 
the  distal  segment  and  taking  wp  the  serous  and  muscular  coats  of  the 
proximal  segment.  This  method  Avould  appear  to  be  quicker  than,  and 
quite  as  reliable  as,  Rogers'  method. 


MAUXSELL's  METHOD  OF  EMEEOEEAPHY.  233 

MODIFICATIONS     OF     CIRCULAR     ENTEROERAPHY.       AIDS 
TO   ITS   PERFORMANCE,    OR  MEANS   OF  REPLACING  IT. 

Owino-  to  the  objections  which  some  have  raised  against  circular 
enterorraphy.  other  methods  have  been  invented.  I  propose  only  to 
describe  those  which  have  stood  the  test  of"  successful  trials  in  the 
human  subject,  as  well  as  giving  good  results  in  animals. 

Method  of  MaunselL* — This  modification  of  circular  enterorraphy 
is  based  on  the  fact  that,  when  Nature  performs  enterorraphy  success- 
fully, she  does  so  by  the  process  of  invagination,  adhesive  inflammation, 
and  sloughing.  The  two  ends  of  the  bowel  f  are  brought  together  by 
two  long  temporary  sutiires  passed  through  all  the  coats  of  the  intes- 

FlG.  60. 


TLis  aud  the  next  three  figures  bbu.v  Maausell'a  moJilicat'oii  of  circular 
enterorraphj'  A  B  C,  Peritonaeal,  muscular,  and  mucous  coats.  F,  Mesenterj-. 
D  D,  Temporarj-  sutures  by  which  the  lower  is  invagiuated  into  the  upper  end; 
they  are  seen  to  emerge  through  a  slit  in  the  latter.  (From  Walsham's  Surgery  ; 
copied  from  Maunsell,  lov.  aifjjra  eit.) 

tine  (D,  D,  Fig.  60),  one  being  placed  at  the  mesenteric  junction,  and 
the  other  exactly  opposite.  These  sutures  secure  the  peritoneeal  cover- 
ing of  the  intestine,  and  serve,  later,  to  effect  invagination.  A  slit 
about  an  inch  and  a  half  long  having  been  made  in  the  long  axis  of  the 
free  border  of  the  proximal  part  of  the  intestine,  about  an  inch  from  the 
divided  end  of  the  gut,  these  two  long  sutm-es  are  passed  up  through 
the  lumen  of  the  bowel  and  out  of  the  slit ;  when  pulled  upon,  the 
smaller  or  distal  end  of  the  bowel  will  be  invaginated  into  the  larger, 
and  drawn  out  of  the  opening  in  this  (Fig.  61).  From  this  figure, 
which  shows  the  relative  position  of  the  layers  invaginated,  it  will  be 
seen  that  the  peritonteal  surfaces  are  in  accurate  apposition  all  round. 
While  an  assistant  holds  the  ends  of  the  temporary  sutures  u])  and 
apart,  the  surgeon  passes  a  long,  fine,  straight  needle,  carrying  stout 

*  H.  "Widenham  MaunselL  late  Lecturer  on  Surgery.  Otago  tTniversity  (^Ainer. 
Jonrn.  Med.  Sci.,  March,  1892).  The  inventor  used  his  method  first  as  long  ago  as  1S86. 
after  resection  of  the  small  intestine  ■•  for  cancer  "  in  a  child  aged  6.  The  child  sank 
on  the  sixth  day ;  at  the  necropsy  the  segment  of  the  intestine  showed  no  evidence  of 
leakage.  Dr.  Wiggins  (^New  York  Med.  Journ..  Dec.  i,  1894,  *"'^  "^  l^i^  pamphlet,  for 
which  I  am  indebted  to  him)  relates  a  successful  case  in  which  he  resected  six  inches 
of  ileum  for  contusion  and  perforation,  uniting  them  by  this  method.  The  patient 
was  well  ten  months  later.  Dr.  Wiggins  mentions  a  case  of  Dr.  Harlcy's  (AVn?  York 
Med.  Jonrn..  vol.  Ivi.  pp.  302  and  464),  in  which  this  method  was  also  successfully 
employed  for  the  resection  of  a  double  intussusception  and  carcinoma. 

t  The  preliminary  steps  as  to  clamps,  &;c.,  would  be  the  same  as  those  given  at  p.  259, 


234 


OPERATIONS  ON  THE   ABDOMEN. 


horsehair  or  very  fine  silkworm  gut,  tlirough  both  sides  of  the  bowel, 
taking  a  good  grip  (a  quarter  of  an  inch)  of  all  the  coats  (Fig.  62). 
The  suture  is  then  hooked  up  from  the  centre  of  the  invaginate'd  gut, 
divided,   and  tied   on  both  sides.     In  this  way,  ticerdij  sutures  can  he 


Fig,  61 


Ct,  The  iuterior  of  the  lower  segment  which  is  invaginated  into  and  through 
the  opening  in  the  upper  segment,  H.* 


Fig.  62. 


A,  The  needle  introducing  two  sutures  by  a  single  transit.     G  and  H  as  before. 

rapidly  lilaced  in  position  with  ten  passaijes  of  the  needle.^  The  temporary 
sutures  are  now  cut  off  short,  the  sutured  ends  of  the  bowel  painted  vxith 
Wolfler's  mixture  of  alcohol,  glycerine,  and  colophonium,  and  dusted 

*  Mr.  Stanley  Boyd  in  his  case  made  the  incision  in  the  distal  end.  and  invaginated, 
with  a  little  difficulty,  the  upper  larger  into  the  lower  small  end. 

t  Mr.  Stanley  Boyd  introduced  here  two  or  three  modifications  of  this  important 
stage,  M-hich  may  be  useful.  Finding  that  time  was  lost  in  drawing  up  the  loops  from 
the  lumen  of  the  bowel,  and  in  selecting  corresponding  ends,  he  passed  many  of  these 
sutures  not  across  the  lumen  of  the  bowel  but  through  only  two  walls,  and  tied  the 
sutures  as  they  were  inserted.  He  found  that  great  care  was  needed  to  ensure  that  the 
cut  edges  of  the  periton^eal  coats  were  equally  drawn  up,  and  that  each  stitch  passed 
a  good  quarter  of  an  inch  below  them,  for  the  mucous  membrane  tends  to  prolapse 
and  to  conceal  the  peritonseal  edges  which  are  of  chief  importance.  Finally,  finding 
the  ends  of  the  wet  silk  difficult  to  push  up  and  disentangle,  he  used  horsehair.  This, 
if  sterilised,  and  not  brittle,  is,  as  Mr.  Boyd  says,  a  safer  material  for  a  penetrating 
stitch.  The  late  Dr.  Maunsell  strongly  recommended  it  as  superior  to  silk.  The  longest 
and  strongest  hairs,  without  a  flaw,  must  be  selected.  Those  from  the  mares'  tails  are 
unreliable,  being  often  rotten  with  urine.  "When  selected  they  should  be  well  brushed 
in  soap  and  water.  They  are  then  next  placed  to  soak  in  a  mercury  bichloride  solution 
for  two  or  three  hours,  then  shaken  out  and  placed  in  a  large  glass-stoppered  bottle. 
Before  being  used,  the  hair  should  be  soaked  for  three  hours  in  a  similar  solution  to 
make  it  pliable  (loc.  giqfra  cit.). 


MAUNSELL'S  METHOD  OF  ENTERORRAPHY.       235 

Avith  iodoform.  The  invaginated  gut  is  then  pulled  back.*  Finally, 
the  longitudinal  slit  in  the  gut  is  well  turned  in,  and  closed  by  a 
Lembert's  continuous  suture,  and  painted  and  dusted  as  above.  The 
appearance  of  the  gut  is  now  as  in  Fig.  63  ;  the  serous  surfaces  should 
be  in  accurate  apposition,  and  all  the  knots  inside  the  bowel.  Dr.  F.  H. 
Wiggins  (loc.  supra  cit.),  comparing  this  method  and  Murphy's  button, 
pointed  out  the  following  as  requiring  careful  attention  when  this 
method  is  employed :  i .  The  mesenteric  border  nuist  be  carefully  ap- 
proximated. 2.  The  sutures  must  be  interrupted,  and  not  placed  too 
near  the  edge  of  the  intestine;  they  should  be  placed  a  quarter  of 
an  inch  from  it,  at  least.  3.  They  must  not  be  tied  too  tightly. 
4.  Too  much  force  must  not  be  used  in  reducing  the  invagination,  or 
the  sutures  may  cut  out.  5.  In  closing  the  longitudinal  incision,  too 
much  of  the  edges  must  not  be  turned  in,  or  a  contraction  may  result. 
While  this  method  is  less  alluring  than  Murphy's  button,  and  cannot 

Fig.  63. 


Tliis  shows  the  Hue  of  juuctiou,  the  peritonaBum  well  turned  iu,  and  the  sutures 
and  knots  nearly  all  inside  tlie  gut.  One  or  two  sutures  are  seen  in  the  mesentery. 
G  and  H  as  before.  Above  H  would  be  the  longitudinal  slit  sewn  iip  by  a  continu- 
ous suture. 

be  used  so  rapidly,  it  has  certain  advantages  over  it  which  it  shares 
with  circrlar  enterorraphy,  and  certain  pectiliar  to  itself.  Thus,  it 
needs  no  mechanical  device,  which  ma}^  not  be  at  hand  just  when 
wanted.  It  requires  only  a  few  needles,  silk  or  horsehair.  Thus,  in 
Dr.  Wiggins's  account  of  his  own  case,  in  which  he  resected  six  inches 
of  the  ileum  for  contusion  and  perforation,  uniting  the  ends  by  Maun- 
sell's  method,  he  writes  (loc.  siqyi^a  cit.):  "The  urgenc}'  of  this  case  was 
great.  The  patient  was  in  a  country  farmhouse.  The  operation  could 
not  have  been  safely  delayed  one  hour  longer  than  it  was ;  consec[uently, 
there  A\'as  no  time  to  procure  mechanical  devices  from  the  city.  x\.  few 
instruments,  a  paper  of  ordinar}^  sewing-needles — milliners'  No.  6 — and 
some  iron-dyed  silk  were  easily  procured,  and  the  operation  was 
promptly  performed,  and  the  patient's  life  saved." 

The  advantages  which  are  claimed  over  circular  enterorraphy  are  that 
this  modification  is  speedier  of  execution,  and  that  it  gives  easier  com- 
mand over  the  ha?morrhage.  A  third  is  that,  when  the  ends  are  of 
unequal  size,  they  can  be  more  readily  dealt  with  by  the  invagination 
of  this  method  than  by  circular  enterorraphy.  The  chief  objection  to 
be  brought  against  it  is  the  additional  wound  through  which  the  tem- 
porary invagination  has  to  be  made.  Having  compared  this  method  with 
Murphy's  button  (p.  236),  it  is  right  that  I  should  add  that  Dr.  Eicketts, 

*  If,  now,  there  is  any  doubt  about  the  line  of  suturing,  a  few  Lembert's  sutures 
should  be  added  externally,  especially  about  the  mesenteric  junction  ;  or  an  omental 
^raft  (p.  267)  may  be  added  (Stanley  Boyd,  Jlcd.-Chir.  I'^'oc.  Trir us. .-\ol.  xxvi.  p.  345). 


236 


0PERATI0X8  ON  THE  ABDOMEN. 


Fig.  64. 


Murphy's  button,  a,  Male  half. 
B,  Female  half.  p,  Spriiig-flauge. 
s  s,  Springs  projectmg  through  open- 
ings in  hollow  stem.  At  c,  part  of  the 
cap  of  the  small  half  has  been  cut 
awaj"  to  show  the  circular  spring  whicli 
keeps  up  the  pressure  as  the  button 
does  its  work.  The  round  holes  in  the 
caps  are  for  drainage.  (This  and  the 
next  three  figures  are  borrowed  from 
Down's  pamphlet,  1894.) 

Fig.  6^. 


/',  Puckeruig  thread,  n  shows  the 
return-stitch  by  which  the  intei-val  be- 
tween the  two  layers  of  the  mesentery 
is  closed — a  very  important  detail. 


of  Cincinnati  (Ann.  of  Surg.,  vol.  i. 
1894,  p.  473),  after  resecting  four 
inches  of  the  ileum  for  carcinoma, 
on  attempting  "  to  make  a  Maunsell 
operation,"  found  that  the  distal  end  of 
the  gut  was  so  fixed,  it  being  only  five 
inches  from  the  ileo-caecal  valve,  that 
more  time  would  be  consumed  than 
was  for  the  good  of  the  patient.  He 
accordingly  used  the  Murphy's  button, 
which  took  only  eight  or  ten  minutes. 
The  patient,  who  had  persistently  re- 
fused operation,  sank  ten  hours  later. 
Dr.  Ricketts,  while  '•  satisfied  that  the 
button  was  the  most  appropriate  in 
this  case,"  is  "  thoroughly  convinced 
that  the  Maunsell  operation  is  the  one 
to  be  used  in  the  majority  of  cases." 

Murphy's  Button  (Figs.  64  ta 
6j). — This,  one  of  the  most  ingenious 
inventions  of  the  last  century,  we 
owe  to  Dr.  J.  B.  Murphy,  of  Chicago 

Fig.  66. 


Showing  method  of  holding  button  for  insertion.* 

(New  York  Med.  Record,  Dec.  lo,  1892). 
Its  great  advantage  is  the  facility  and 
rapidity  Avith  which  end-to-end  ap- 
proximation can  be  effected  without 
an}'  sutures.  The  button  consists  of 
two  halves.  The  male  half  has  a  spring* 
flange  for  keeping  up  pressure  on  the 
intestine  ends.  Two  springs  (s,  s),  pro- 
jecting through  openings  in  the  hollow 
stem,  act  as  a  male  thread  of  a  screw,, 
when  the  male  half  is  telescoped  Avithin 
the  female  half  of  the  button.  When 
the  button  is  used  to  unite  resected 
ends  of  bowelf  a  puckering  or  running- 
thread  is  passed  round  each  side 
to    and    from   the  attachment    of   the- 


*  The  male  half  of  the  button  is  held  in  the  same  way.  The  figure  representing  the 
forccp.s  holding  the  male  half  of  the  button  has  been  omitted,  as  it  shows  the  forceps  in 
a  wrong  position.   Mr.  Cathcart,  of  Edinburgh,  has  kindly  drawn  attention  to  this  point, 

f  Its  use  in  effecting  lateral  anastomosis  is  given  at  p.  269. 


MUEPHY'S  BUTTON.  237 

mesentery,  and  es]iecial  care  is  taken  to  close  the  triangular  interval 
which  exists  here  (Figs.  59  and  65),  by  means  of  the  return  stitch.  One 
half  of  the  button,  held  as  in  Fig.  66,  is  then  inserted  in  the  intestine, 
and  the  running  thread  so  tightened  as  to  pucker  the  cut  end  of  the 
intestine  with  sufficient  closeness  and  tightness  around  the  shaft  of  the 
button.  The  ends  of  the  thread  are  then  tied  and  cut  short.  The  other 
half  of  the  button  having  been  secured  in  the  opposite  end  of  the  intes- 
tine (Fig.  6j),  the  two  halves  are  gently  pressed  together,  the  surgeon 
having  first  made  sure  that  both  cut  ends  are,  all  along  their  edges,  within 
the  grasp  of  the  button.  The  two  halves  are  pressed  together  until  it 
is  seen  that  the  peritonaeal  surfaces  are  held  in  sufficiently  close  and 
accurate  contact.  Dr.  Murphy  holds  that  it  is  needless  to  apply  Lem- 
bert's  sutures  with  the  button  between  the  serous  surfaces,  and  that 
scarification  of  these  is  also  unnecessary.* 

Dr.  Murphy  (Lancet,  vol.  i.  1895,  p.  1040)  claims  for  his  button  that 
in  resection  of  intestine  for  gangrenous  hernia  it  has  been  used  twelve 
times  with  two  deaths.  In  resection  for  malignant  disease  there  have 
been  thirty  operations  with  seven  deaths,  these  thirty  including  eight 

Fig.  67. 


Murphy's  method  of  end-to-euct  approximatiou  uf  divided  iutestine.  The  two 
halves  of  the  button,  each  secured  by  a  puckering  thread,  are  ready  to  be  pushed 
home. 

cases  of  resection  of  the  ca3cum  with  but  one  death.  With  regard  to 
two  of  the  cases  of  fatal  peritonitis.  Dr.  Murphy  points  out  that  in  one 
the  button  was  too  large  and  fitted  too  tightly.  To  prevent  tension  the 
button  should  fit  easily.  In  another  case  both  ends  of  the  intestine  were 
found  to  be  gangrenous  at  the  necropsy.  This  is  stated  to  have  been 
due,  not  to  the  button,  but  to  the  length  of  time  during  which  the 
intestine  was  clamped  during  the  operation. 

The  modus  operandi  of  the  button  is  based  upon  the  following  prin- 
ciples :  (i)  It  retains  apposition  automatically — that  is,  without  suture. 
Thus  the  danger  of  shock,  the  length  of  the  manipulation  and  exposure 
of  the  intestine,  the  risk  of  infection,  post-operative  paralysis,  and  adhe- 
sions, are  very  greatly  lessened,  and  an  immense  saving  of  time  secured. 
(2)  The  pressure-atrophy  is  produced  by  elastic  pressure ;  this  being- 
uniform  and  continuous,  the  assurance  of  adhesions  is  greater  and  the 
risk  of  infiltration  less.  It  produces  juxtaposition  of  the  edges  of  the 
same  coats,  thus  minimising  the  interposition  of  fibrous  tissue,  and  per- 
fecting the  regeneration  along  the  line  of  union.     As  a  result,  the  union 


*  The  following  precautions  are  given  as  to  the  button  and  its  use.  The  edge  of  the 
cup  should  never  be  sharp,  but  possess  a  line  of  surface.  The  spring  must  not  be  too 
stiff,  or  it  might  produce  too  rapid  sloughing.  The  locking  should  be  eas3%  Unneces- 
sary handling  of  the  buttons  should  be  avoided.  They  should  be  left  partially  un- 
screwed, until  wanted  for  use. 


238  OPERATIONS  ON  THE  ABDOMEN. 

is  accomplished  ^^'itll  the  smallest  possible  cicatrix,  and  therefore  must 
yield  the  least  contraction  of  any  oi:)eration.  Believing  that  he  had 
absolutely  established  the  above,  Dr.  Murphy  claimed  that  his  button 
attained  the  best  results  in  intestinal  approximation  because  it  best 
attained  the  following  ends :  (a)  Accurate  contact  of  surface.  (yS)  Speedy 
and  permanent  adhesion  of  the  approximated  surfaces.  (7)  An  opening 
sufficient!}'  large  for  immediate  purposes.  (8)  A  cicatrix  that  v.'i\\  not 
contract  harmfullv.  (e)  The  accomplishment  of  all  these  in  the  most 
simple  and  rajnd  manner. 

Objections. — Dr.  Murphy's  method  is  so  alluring  in  its  ingenuity,  the 
simplicity  and  readiness  with  which  it  can  be  applied  are  so  evident,  that 
there  is  some  danger  of  its  disadvantages  *  being  lost  sight  of.  The 
following  appear  to  me  to  be  established  : 

(i)  Contraction  of  the  orifice. f  When  the  modus  operandi  of  the 
button  is  considered  this  risk  must  always  be  remembered.  In  the 
words  of  an  American  surgeon  who  has  taken  much  practical  interest 
in  intestinal  surgery  (Dr.  McGraw,  of  Detroit) :  "In  the  operation  by 
Murphy's  button,  the  button  becomes  detached  by  crushing  the  rim  of 
tissue  around  the  opening  of  communication  until  it  sloughs  and  gives 
way,  leaving  behind  a  granulating  wound,  disposed  to  close  after  the 
nature  of  such  wounds"  (A'/m.  of  Surg.,  vol.  ii.  1893.  p.  315).  A  case 
of  Prof.  Keen's,  of  ileo-colostomy,  for  carcinoma  of  the  colon,  by  means 
of  the  button,  is  an  instance  of  the  truth  of  the  above  : 

The  button  had  been  passed  on  the  twelfth  day,  "  together  with  a  slough  consisting 
of  the  rings  of  tissues  between  the  two  halves  of  the  button.  The  patient  died  very 
suddenly  of  a  perforating  ulcer  of  the  colon,  forty-seven  days  after  the  operation,  and 
the  necropsy  showed  that  the  opening  had  already  contracted  to  one-half  of  its  original 
diameter. 

Prof.  Keen  considers  the  possible  contraction  of  the  anastomotic 
opening  "  the  pivotal  point  upon  which  rests  the  utility  of  the 
button." 

Dr.  Dawbarn,  of  New  York,  a  strong  advocate  of  vegetable  plates  in 
intestinal  surgery,  had  earlier  {Ann.  of  Surg.,  vol.  i.  1893,  p.  155) 
expressed  a  fear  which  this  case  of  Prof.  Keen's  proves  to  have  been 
well  grounded  :  "In  performing  cholecyst  enterostomy  it  (the  button) 
really  seems  an  ideal  plan ;  but  upon  stomach  and  in  uniting  bowel  to 
bowel,  because  of  the  primary  small  calibre  of  the  new  opening  (still 
further  to  be  reduced  with  time),  I  venture  to  predict  a  justified  lack  of 
acceptance  by  the  profession."  The  following  case  of  Dr.  E.  Abbe,  of 
New  York  {Ann.  of  Surg.,  April  1895),  shows  that  even  after  chole- 
cystenterostomy  such  stenosis  may  follow  as  to  prevent  fluid  contents 
such  as  bile  from  passing : 

About  a  year  before,  Dr.  R.  Abbe  had  opened  the  gall-bladder,  establishing  a  fistula 
in  a  woman  who  had  cancer  involving  the  head  of  the  pancreas  and  first  part  of  the 
common  duct,  causing  obstruction  and  distension  of  the  gall-bladder.     The  patient's 

*  Dr.  Murphy,  in  a  verj''  interesting  paper  on  "  Operations  with  the  Murphy  Button  " 
(^Lancet,  vol.  i.  1895,  P-  1040),  makes,  I  think,  too  light  of  these.  Several  of  his  conclu- 
sions as  to  contraction  of  the  scar  left  by  the  button,  fjecal  impaction,  and  sloughing, 
are,  it  seems  to  me,  not  justified  by  the  published  cases  {vide  infra). 

t  Dr.  Murphy  (luc.  supra  rit.')  states  first  amongst  the  conclusions  at  which  he  haS 
arrived — "  The  cicatrix  produced  with  the  button  does  not  contract."  No  mention  is 
made  of  Prof.  Keen's  case  given  below. 


MURPHY'S  BUTTON.  239 

condition  having  greatly  improTod  in  six  weeks,  Dr.  Abbe  established  an  anastomosis 
between  the  gall-bladder  and  duodenum  with  a  Murphy's  button.  This  was  passed 
on  the  twelfth  day.  The  patient  remained  in  excellent  health  for  eight  months,  when 
symptoms  of  gall-stone  colic  recurred,  making  it  probable  that  stenosis  was  taking 
place.  The  symptoms  returned,  and  the  patient  died  in  the  third  attack  with  cholsemia 
and  convulsions.  The  opening  created  between  the  gall-bladder  and  duodenum  had 
become  absolutely  closed  by  cicatricial  contraction  ten  months  after  its  establishment. 
The  malignant  disease  had  not  invaded  the  anastomosed  parts. 

(2)  Sloughing  at  the  line  of  junction,  and  extravasation  of  fceces. 
The  following  case  of  Dr.  Abbe's  (Anii.  of  Surg.)  is  a  proof  of  the  risk 
of  the  above : 

The  patient  was  admitted  with  obstruction  due  to  carcinoma  of  the  sigmoid.  Owing 
to  the  distension  and  the  condition  of  the  patient,  a  lateral  anastomosis  above  and 
below  the  cancer  was  done  with  a  button.  Six  weeks  later,  resection  was  undertaken, 
owing  to  the  pain  felt  locally.  The  anastomosed  gut  was  resected,  and  an  end-to-end 
anastomosis  made  "  by  a  large  button  which  fitted  rather  snugly  in  the  lower  end." 
The  cancer  had  by  this  date  invaded  the  lumbar  wall.  A  counter-opening  was  made 
behind,  and  the  anterior  one  closed.  On  the  fourth  day,  faeces  appeared  at  the  lumbar 
wound.  On  the  sixth  day  this  was  freely  opened,  and  the  intestine  found  to  be  slough- 
ing on  either  side  of  the  button.     On  the  seventh  day  the  patient  died  exhausted. 

It  is  only  fair  to  Dr.  Murphy  to  point  out  that  this  was  a  veiy  severe 
test  for  his  method.  The  patient  was  "not  in  ver}-  good  condition  after 
the  operation,"  and  it  is  possible  that  the  separation  of  adhesions  and 
the  extension  of  the  growth  had  interfered  with  the  blood  supplv  of  the 
intestine,  though  this  is  not  stated. 

Moreover,  the  button  was  undoubtedly  a  large  one,  for  it  "  fitted 
rather  snugly,"  and  in  this  lies  the  answer  to  the  above  objection,  for  a 
button  which  in  any  degree  stretches  the  intestine  will  be  liable  to  cause 
sloughing  opposite  the  outer  rim.  This  has  undoubtedly  been  the  cause 
in  other  cases  where  this  accident  has  happened. 

(3)  Septic  peritonitis  due  to  sloughing  of  the  intestine  over  the 
button.  When  we  consider  that  in  anastomosis  of  the  intestine  we  can 
never  keep  the  field  of  operation  aseptic,  and  that,  whatever  method  we 
use,  needles,  sutures,  plates,  buttons,  &c.,  may  all  be  the  means  of 
increasing  sepsis,  no  surprise  will  be  felt  when  occasionally  cases  are 
published  in  which  septic  peritonitis  has  followed  on  the  use  of  the 
button.  Its  modus  operandi  is  by  setting  up  a  limited  pressure-gangrene 
or  sloughing.  In  many  cases  this  process  will  be  limited,  but  it  is 
manifestly  impossible  to  control  or  limit  such  a  process,  and  occasionally 
fatal  results  will  be  met  with  from  this  cause. 

Mr.  Harrison  Cripps  {loc.  svpra  cit.)  mentioned  a  case  in  which  the  patient  died  in 
two  or  three  days  from  acute  septic  peritonitis  due  to  sloughing  of  the  intestine  over 
the  upper  half  of  the  button. 

Prof.  Senn  speaks  very  strongly  on  this  point  {Journ.  Amer.  Med. 
Assoc,  vol.  ii.  1893,  p.  232):  ''It  is  impossible  to  efiect  an  aseptic 
incision  in  the  interior  of  the  bowel ;  the  dead  tissue  inhabited  by 
pathogenic  microbes  always  constitutes  a  source  of  danger.  It  is  easy 
enough  to  produce  gangrene,  but  we  are  powerless  in  limiting  its 
extension  in  this  locality.  The  limited  area  of  living  tissue  brougTit  in 
contact  outside  of  the  rings  of  the  Murphy  button  will  not  always  prove 
adequate  in  the  protection  of  the  peritoneal  cavity  against  perforation 
and   its   immediate   result — septic  peritonitis.     I   have  ■  knowledge  of  a 


240  OPERATIONS  OX  THE  ABDOxAIEN. 

number  of  cases  in  which  the  parts  approximated  by  the  Murphy  button 
were  found  completelj^  separated  at  the  post-mortem  examination." 

(4)  Retention  of  the  button,  causing  obstruction.  I  shall  allude  to  a 
case,  under  the  heading  of  Gastro-jejunostomy  (p.  331),  where  the  button 
had  not  been  passed  but  no  harm  had  followed.  A  number  of  similar 
cases  have  been  recorded. 

The  following  show  that  the  button  may  cause  fatal  obstruction  : 

Dr.  H.  Abbe  (Ann.  of  Surg,')  has  related  a  case  of  resection  of  the  caput  coli  and 
ascending  colon  for  cancer  in  a  patient  aged  42.  An  end-to-end  anastomosis  was 
easily  made  with  a  medium-sized,  easy-fitting  Murphy  button.  At  the  end  of  the 
second  day  there  was  abdominal  pain,  with  tympanites  and  vomiting.  Strong  desire 
to  defiEcate  was  futile,  even  with  the  aid  of  a  high  enema.  Saline  cathartics  were 
useless.  On  the  third  day  after  the  operation  the  greatly  distended  ileum  was  sutured 
to  the  abdominal  wall  and  opened.  A  large  amount  of  fluid  fseces  escaped  with  great 
relief.  The  patient  died  on  the  sixth  day.  The  necropsy  showed  no  peritonitis,  but  an 
empty  colon  below  the  button,  and  a  hard  plug  of  f^ces  in  the  button,  which  caused 
complete  obstruction. 

Dr.  Kammerer  {Ann.  of  Surg.)  has  recorded  a  case  in  which  the 
button  caused  trouble  by  not  passing  in  the  small  intestine. 

The  case  was  one  of  fjecal  fistula,  resulting  from  a  gangrenous  hernia.  Anastomosis 
had  been  made  by  a  Murphy's  button.  Thirteen  weeks  later  the  button  had  not  been 
passed,  but  could  easily  be  reached  from  the  fjecal  fistula  which  still  persisted.  Dr. 
Kammerer  enlarged  the  fistula,  and  after  much  trouble  succeeded  in  extracting  the 
button.  The  patient  did  well  for  six  days,  when  she  developed  symptoms  of  sub- 
acute peritonitis  and  died.  The  necropsy  showed  general  peritonitis.  The  anastomosis 
had  separated  while  the  button  was  being  removed,  and  the  sharp  edges  of  the  incision 
into  the  bowel  showed  that  the  adhesions,  even  after  thirteen  weeks,  must  have  been 
very  slight.  Dr.  Kammerer  did  not  believe  that  the  peritonitis  was  due  to  a  separation 
at  this  point,  but  any  other  explanation  for  it  was  not  apparent. 

Mr.  Harrison  Cripps  (^Brit.  Med.  Journ.,  vol.  ii.  1895,  P-  9^5)  mentioned,  in  the 
discussion  on  Colectomy,  a  case  in  which  the  patient  died  on  tlie  eighth  day  from 
perforative  peritonitis  caused  by  the  button  having  become  impacted  six  inches  below 
the  point  of  anastomosis,  and  having  ulcerated  through. 

(5)  Kinking  and  strangulation  from  the  weight  of  the  button.  This 
is  rare,  but  a  case  of  Dr.  Abbe's  is  related  of  this  kind  {Ann.  of  8urg.) . 

Five  inches  of  small  intestine  had  been  resected  for  gangrene  in  a  hernia.  The  two 
ends  having  been  joined  by  Murphy's  method,  the  loop  containing  the  button  was 
replaced,  and  Bassini's  operation  performed.  Before  the  wound  was  entirely  closed, 
Dr.  Abbe  looked  in  and  noticed  that  the  upper  end  of  the  gut  was  still  distended. 
This  was  due  to  the  button  kinking  the  gut  as  it  lay  in  the  iliac  fossa.  The  loop  was 
accordingly  pushed  towards  the  middle  of  the  abdomen,  in  the  belief  that  it  would 
settle  and  rest  easily  among  the  other  coils.  Symptoms  of  strangulation  recurred,  and 
forty-eight  hours  after  the  first  operation  Dr.  Abbe  reopened  the  abdomen  and  found 
the  kink  persisting,  the  bowel  having  gravitated  to  the  lowest  point  in  the  pelvis. 
The  patient  only  survived  the  operation  a  short  time.  It  seemed  that  the  weight  of 
the  button  had  given  rise  to  the  acute  obstruction  by  sharply  bending  the  gut. 
Probably  this  was  aided  by  the  paralysed  condition  of  the  bowel  so  common  in  these 
cases. 

(6)  Mr.  Mayo  Robson,  in  a  speech  at  the  Clinical  Society,  pointed 
out  that  if  any  error  was  made  in  applying  the  button,  it  might  be 
impossible  to  unfasten  it  for  readjustment.  He  stated  that  under 
such  circumstances  an  operator,  in  order  to  set  the  button  free,  had 
found  it  necessary  to  excise  afresh  the  portion  grasped  by  the  button. 


MAYO  ROBSON'S  BOBBIN. 


241 


Tic.  es. 


(7)  Anotliei'  objection  of  a  very  different  kind  may  be  just  alluded 
to,  and  that  is,  its  expense,  and  the  difficulty  of  always  havino-  the 
right  size  at  hand.  This  in  no  way  detracts  from  the  ingeniousness  of 
the  button,  nor  do  I  bring  it  forward  as  a  serious  objection.  It  is  right, 
however,  that  it  should  be  mentioned  Avhen  this  mode  of  intestinal 
junction  or  anastomosis  is  fairly  weighed  with  enterorraph3^  Robson's 
bobbin,  &c. ;  this  last  is,  of  course,  required  in  several  sizes,  but,  being 
far  less  expensive,  will  be  more  readih'  near  at  hand  in  sufficient 
variety. 

I  am  well  aware  that  these  cases  given  above  are  but  few  when 
compared  with  the  large  number  of  brilliant  successes  which  Dr. 
Murphy's  button  has  attained.  It  is  right,  however,  that  they  should 
be  published,  as  there  is  strong  reason  to  believe  that  the  button 
has  been  used  on  many  occasions  unsuccessfully,  these  cases  never 
being  published.  Again,  it  is  noteworthy  that  the  failures  which 
have  been  published  have  occurred  in  the  hands  of  most  skilful 
surgeons.  I  fear  that  the  extreme  ingenuity  of  the  button,  the  facility 
with  which  it  can  be  used,  may  tempt  men  far  less  competent  to  perform 
operations  for  which  they  are  unfitted, 
with  results  that  will  not  be  made  public. 
Konig  (Cenir.  f.  Chir.,  No.  4,  1895),  I 
find,  has  expressed  the  same  view.  Thus, 
"  The  use  of  Murphy's  button  may  extend 
the  practice  of  resection,  and  so  enable 
inexperienced  sui-geons  to  perform  these 
operations,  but  this,  from  the  patient's 
point  of  view,  is  rather  a  disadvantage 
than  a  sign  of  advance." 

MayoRobson's   Bobbin    (Figs. 

68.  69.  /O). — This  method  appears  to 
me  iikel}",  for  the  present,  at  all  events, 
to  replace  all  the  other  special  apparatus 
which  have  been  invented  to  aid  in  the 
resection  or  anastomosis  of  the  stomach 
and  intestines. 

Mr.  Robson  (Brit.  Med.  Journ.,  vol.  ii.  1895,  P-  9^3)  states  that,  after 
using  or  seeing  used  all  the  other  usual  contrivances,  e.g.,  Senn's  plates, 
^lurphy's  button,  and  Paul's  tubes,  he  has  returned  in  enterectomy  to 
the  use  of  the  bobbin,  which  "  I  infinitely  prefer,  not  only  on  account  of 
its  simplicity  and  safety,  but  because  it  can  be  employed  quickly,  secures 
an  immediately  patent  channel,  leaves  no  foreign  body  permanently  in 
the  passage,  avoids  stricture  by  securing  continuity  of  mucous  surface, 
and  can  be  adapted  to  any  of  the  operations  on  the  intestinal  canal."* 
Another  advantage  which  may  be  safely  claimed  is  that  these  bobbins 
are  much  more  easily  introduced  when  one  segment  of  intestine.  e.<j..  the 
lower  usually,  is  much  narrower  than  the  upper.  Again,  from  their 
shape,  they  obviously  will  exert  much  less  tension  upon  the  intestinal 


Mayo-Eobson's  decaleilied  boue 
bobbin.  These  are  made  in  five 
sizes,  for  junction  of  gall-bladder 
and  intestine,  stomach  and  intes- 
tine, to  unite  resected  small  intes- 
tine, colon,  and  rectum.  The  above 
is  the  size  used  for  tlie  colon. 


*  It  will  ba  a  very  great  gain  if  surgeons  find,  as  claimed  by  Mr.  M.  Robson  QLa 

Semaine  Medicale.  1892,  p.  482).  that  there  is   one  contrivance  ready  to  their  hands 

calling  for  much  the  same  technique  in  all  such  varied  operations  as  enterectomy, 

intestinal  anastomosis,  ileo-colostomy,  pylorectoray.  pyloroiilasty,  cholecystenterostomy. 

VOL.   II.  '      '  16 


242  OPERATIONS  ON  THE  ABDOMEN. 

wall  and    the  sutures  which    hold   them   together,  than    the  plates  of 
Prof.  Senn. 

The  decalcified  bone  bobbins  were  in  their  first  issue  like  a  cotton- 
reel,  the  rims  at  the  ends  being  (Fig.  69)  made  larger  than  its 
centre  in  order  to  prevent  the  body  shifting  from  its  place  until  its 
pressure  is  not  needed.  These  rims  being  found  too  prominent,  the 
bobbin  was  modified  as  shown  in  Fig.  68.  The  following  account  is 
taken  from  La  Sent.  Med.,  loc.  infra  cit.  (Figs.  69,  70):  "It  seemed 
that  if  one  could  secure  continuit}'  of  the  mucous  coat  across  the  new 
aperture  by  means  of  a  continuous  suture  (Fig.  69)  sewn  around  a  tube 
without  the  risk  of  narrowing  the  size  of  the  orifice,  one  would  be  able 
to  avoid  consecutive  cicatricial   narrowing.      The  union  of  the  serous 


Fig.  69. 


The  continuous  muco-mucous  suture      (Mayo  Robson.) 
Fir,.  70. 


/    V 


The  continuous  sero-serous  suture.     Below  is  seen  the  knotted  end  of  the 
muco  mucous  stitch  which  will  shortly  be  shut  in.     (Mayo  Eobsou.) 

surfaces  could  be  assured  by  means  of  a  sero-serous  suture  made  in  the 
same  way  as  the  mucous,  one  or  one  and  a  half  centimetres  from  the  edges 
of  the  incision,  so  removing  all  risk  of  extravasation  (Fig.  70).  The 
operation  is  facilitated  by  beginning  with  the  sero-serous  suture  for  the 
posterior  half  of  the  incision,  then  putting  in  the  muco-mucous  for  the 
same  extent.  The  tube  is  then  put  in  place,  the  muco-mucous  suture 
next  completed,  and  finall}-  the  anterior  half  of  the  sero-serous." 

Mr.  Mayo  Kobson  (Brit.  Med.  Journ.,  vol.  ii.  1895,  p.  965)  stated  that 
while  usually  employing  two  sutures,  the  mucous  and  serous,  with  his 
bobbin,  he  has  not  hesitated  to  use  only  one  continuous  stitch  to  unite 
the  whole  thickness  of  the  gut  where  time  was  an  object  in  the  case. 


ALLIXGHAM'S  BOBBIN.  243 

In  this  case  lie  claims  that  the  bobbin-operation  can  be  done  more 
quickly  than  that  with  the  button,  and  at  the  same  time  he  believes 
that  it  will  give  greater  security'  against  leakage  and  a  much  firmer 
bond  of  union.  When  the  double  suture  is  used,  Murphy's  button  will, 
Mr.  Robson  thinks,  only  save  three  or  four  minutes,  and  he  points  out 
that  his  five  cases  of  colectomy  are  living  examples  of  the  contrast  of  the 
after-progress  of  the  two  methods.  Thus  in  cases  i.  ii.  and  v.,  where 
the  bobbin  was  used,  an  uninterrupted  recovery  followed ;  in  case  iii.. 
Murphy's  button  took  forty-four  days  to  pass,  and  caused  partial  obstruc- 
tion on  several  occasions.  In  a  list  of  cases  which  Mr.  Robson  prepared 
in  order  to  illustrate  a  paper  read  before  the  Clinical  Society  (Brit.  Med. 
Journ.,  vol.  i.  1896,  p.  451),  the  bobbin  was  used  in  seven  cases  of 
.enterectomy,  and  out  of  these  six  recovered.* 

The  following  advantages  of  this  method  ha^■e,  it  seems  to  me,  been 
fairly  established  : — ( i )  It  facilitates  and  simplifies  circular  enterorraphy. 

(2)  The  foreign  body  on  which  it  depends  is  safely  dissolved,  instead  of 
being  left  behind  to  come   away,  thus  often   giving  rise   to  anxiety. 

(3)  There  is  no  sloughing  connected  with  its  modus  o^ierandi ;  it  pre- 
vents subsequent  stricture  by  establishing  a  continuous  mucous  canal, 
without  the  stage  of  healing  by  granulation.  (4)  Owing  to  the  size  of 
the  bobbin,  and  there  being  no  sloughing  connected  with  it,  the  opening 
provided  is  sufficient  and  permanent.  (5)  Though  at  present  it  has  not 
been  very  largel}"  used,  the  percentage  of  successes  is  very  high.  In 
his  paper,  read  before  the  Clinical  Society,  Mr.  Robson  showed  that  the 
use  of  the  bobbin  had  been  attended  by  a  mortality  as  low  as  8  per  cent. 
(6)  Last,  but  by  no  means  least  in  importance,  is  the  fact  that  the 
bobbin  is  adaptable  to  a  very  wide  range  of  operations.  The  only 
objection  to  it  is  one  common  to  all  mechanical  devices — i.e.,  that  it  is 
not  always  to  hand.  In,  however,  its  cheapness,  its  great  variety  of 
;sizes,  and  the  readiness  with  which  it  can  be  prepared,  it  contrasts 
very  favourably  with  Murphy's  button,  while  from  its  greater  facility 
of  introduction,  absence  of  somewhat  perplexing  threads,  and  the  safer 
tension  it  exerts  upon  opposed  or  approximated  segments,  it  seems  to 
me  to  be  a  distinct  advance  upon  the  bone  plates  of  Prof.  Senn, 
making  all  due  allowance  for  the  excellence  of  the  work  which  these 
earlier  devices  of  a  very  brilliant  pioneer  in  abdominal  surgery  have 
done. 

AUingham's  Bobbin  (Figs.  71  to  74).— Mr.  H.  Allingham  has 
introduced  a  bone  bobbin  which  differs  from  Mr.  Robson's  in  shape  and 
structure.  It  consists  of  two  cones  with  the  apices  united  in  the  centre 
(Fig.  71).  They  are  decalcified  to  within  about  three-sixteenths  of  an 
inch  of  their  centre.  The  junction  of  the  two  cones  is  hard  and  unvield- 
ing  to  meet  any  pressure  from  the  sutures  when  tightened.  Besides  the 
advantages  of  other  bobbins  it  is  claimed  that  this  one  cannot  slip  away, 
and  that  when  the  sutures  are  tied  the  parts  resected  are  brought 
together  without  excessive  pressure  on  the  edges  of  the  bobbin.  A 
purse-string  stitch  (Fig.  72)  is  run  round  each  end  of  the  gut :  then 
one  end  of  the  bobbin  is  inserted  into  one  segment  of  the  intestine,  and 
the  suture  is  pulled  tight  by  a  knot  twice  threaded  (Fig.  72),  which 


*  Mr.  Bowlby,  iu  the  discussion  which  followed  Mr.  M.  Eobsou's  paper,  emphasised 
Xhe  lulvantage  of  the  bobbin  in  securing  the  immediate  passage  of  flatus  and  faeces. 


244 


OPERATIONS  ON  THE  ABDOMEN. 


will  not  slip,  but  the  final  tie  is  not  made  until  the  other  end  of  the 
bobbin  has  been  insei'ted  into  the  other  segment  of  intestine.  After  this 
each  suture  is  tightened  to  its  utmost,  the  ends  of  the  intestine  being 
thus  drawn  down  to  the  centre  of  the  bobbin  (Fig.  74).  which  from  its 


Fig.  71. 


Fig.  72 


Fig.  74. 


shape  ensures  that  the  tighter  the  sutures  are  drawn,  the  more  securely 
must  the  intestine  ends  be  drawn  to  meet  in  the  centre  of  the  bobbin. 
A  few  Lembert's  sutures  or  a  continuous  Lembert's  suture  may  be  used 

Fig.  75.  Fig.  76. 

A     8 


-y^^ 


( 


A  B,  Central  part  not 
decalcified,  partly  seg- 
mented by  saw-cut.  C, 
Lumen  in  decalcified  end. 


A  D,  Proximal  and  distal  intestine.  C  E,  Purse-string 
sutures.  B,  Sub-serous  purse-string  suture,  by  which, 
after  union  of  the  intestine,  one  part  is  invagiuated  over 
the  other. 


Fig.  77. 


D 


C,  Proximal  groove  in  which  the  two  marginal  sutures  secure  the  orifices  of 
the  two  parts  of  the  intestine,  A  and  B.  D,  Distal  groove  where  sub-serous 
purse-string  presses  the  proximal  intestine  over  the  invaginated  distal  part. 

if  thought  desirable.  It  is  well  to  lightly  scarify  the  serous  coat  for 
half  an  inch  round  the  union  to  pi^omote  exudation  of  lymph.  This 
button  has  been  successfully  used  once  on  the  human  subject  by  Mr, 
Allingham. 


BAILEY'S  DECALCIFIED  BONE  TUBE. 


245 


Hayes'  Bobbin  (Figs.  75  to  78). — Mr.  Hayes  has  devised  (Lancet, 
vol.  i.  1895,  p.  1 619)  another  ingenious  button,  partly  decalcified,  b}' 
which  he  obtains  additional  security  b}^  easily  invaginating  one  piece  of 

Fig.  78. 


Lateral  anastomosis  by  Hayes'  bobbin.  E  and  F,  Apertures  to  receive 
the  bobbin.  D  and  C,  Marginal  sutures.  K  and  I,  Sub-serous  purse- 
string  sutures. 

resected  intestine  within  the  other.  It  is  not  stated  whether  the  bobbin 
has  been  successfully  used  on  the  living  subject.  The  drawings  are  so 
clear  that  they  explain  this  method  of  themselves. 

Bailey's  Decalcified  Bone   Tube.— Mr.    R.    Cozens    Bailey 

describes  {St.  IJartJt.  Hosp.  E'eport.^^,  1897)  two  successful  cases  in  which 
he  made  use  of  the  tube  shown  in  Fig.  79.  The  first  case  was  one  of 
resection  of  six  inches  of  gangrenous  small  intestine  from  a  strangulated 
inguinal  hernia  ;   the  second,  one  of  artificial  anus  of  long   standing. 

Fig.  79. 


ruLL     SIZE 


Bailey's  decalcified  Ijone  tube. 

The  method  of  using  the  tube  and  the  advantages  claimed  for  it  are  best 
described  in  Mr.  Bailey's  own  words : 

'■  The  intestinal  contents  being  kept  back  by  two  pieces  of  rubber 
drainage-tube  passed  through  the  mesentery  and  tied  round  the  bowel 
some  distance  above  and  below  the  site  of  operation,  so  as  to  be  out  of 
the  way,  and  the  necessary  amount  resected,  a  single  stitch  is  passed  at 
the  mesenteric  border  through  the  whole  thickness  of  both  ends  of  the 


246  OPERATIONS  ON  THE  ABDOMEN. 

gait,  and  tied,  tlins  bringing  tlie  divided  extremities  together  at  their 
attached  margin.  This  is  important,  as  it  not  onh"  prevents  the 
peritongeiim  being  stripped  back,  but  also  greatly  facilitates  the  applica- 
tion of  the  circular  ligatures  at  a  subsequent  stage  of  the  operation. 
The  tube  is  now  passed  into  the  bowel,  and  when  in  position  one  end  of 
the  gut  is  brought  well  down  over  its  corresponding  groove  and  secured 
by  a  silk  ligature  passed  through  the  gap  in  the  mesentery,  and  made 
to  encircle  the  whole  circumference  of  the  bowel  in  such  a  way  that 
when  tightly  tied  it  lies  within  the  groove.  The  part  be3^ond  the  silk 
is  then  trimmed  with  scissors,  so  that  only  just  sufficient  is  left  to- 
ensure  the  ligature  holding.  The  other  end  is  then  treated  in  the  same 
way.  A  little  difficulty  may  be  experienced  here  in  getting  the  ligature 
to  include  the  whole  thickness  of  the  intestine,  the  part  most  liable  to 
escape  being  the  mesenteric  border  ;  but  this  entirely  disappears  if  two 
little  points  which  I  have  insisted  upon  be  observed:  firstly,  the  prelimi- 
nary tying  together  of  the  ends  by  a  suture  at  the  mesenteric  attach- 
ment ;  and  secondly,  the  inclusion  of  a  sufficient  length  beyond  the 
circular  ligatures,  the  excess  being  subsequenth^  removed  with  the 
scissors. 

"At  this  stage  the  operation  site  should' be  thoroughly  flushed  with 
an  antiseptic  solution  in  order  to  remove  any  particles  of  faecal  matter, 
&c.,  which  may  be  present.  The  assistant  now  grasps  the  intestine  at 
a  little  distance  from  the  ligatures,  and  by  approximating  his  hands, 
brings  the  serous  coats  into  contact  in  such  a  way  that,  if  the  proximal 
and  distal  portions  of  the  gut  are  of  ecjual  calibre,  a  point  an  eighth  of 
an  inch  above  the  ujoper  meets  a  point  a  corresponding  distance  below 
the  lower  ligature,  over  the  centre  of  the  space  between  the  grooves  on 
the  tube.  If,  however,  there  is  great  inequality  in  the  sizes  of  the  two 
portions  of  intestine,  the  smaller  can  be  invaginated  into  the  larger,  and, 
as  I  previously  pointed  out,  probably  this  manoeuvre  would  be  more 
easih'  carried  out  by  using  a  conical  instead  of  a  cylindrical  tube. 

"  The  serous  coats  thus  approximated  are  fixed  in  position  by  a  row  of 
Lemberts  sutures.  In  the  case  of  small  intestine,  five  or  six  of  these 
only  will  be  required,  one  on  each  side  close  to  the  mesentery,  which 
should  be  passed  first,  the  remaining  three  or  four  round  the  rest  of  the 
circumference.  The  chief  advantages  which  I  claim  for  a  tube  of  this 
sort  are — 

"  (i)  That  it  provides  the  largest  possible  temporary  channel  for  the 
passage  of  intestinal  contents. 

"  (2)  That  till  it  softens,  or  the  ligatures  cut  through,  the  escape  of 
faecal  matter  is  absolutely  prevented. 

"  (3)  That  since  the  row  of  sutures  takes  no  part  in  keeping  the 
junction  water-tight,  a  sufficient  number  to  keep  the  parts  in  apposition 
only  is  required  ;  and  these  being  few  and  easily  introduced,  the  time 
required  for  the  operation  is  greatly  diminished. 

"  (4)  That  the  tube,  having  fulfilled  its  purposes,  undergoes  absorp- 
tion and  leaves  no  bulky  mass  to  pass  along  the  canal." 

Paul's  Method  (Liverpool  Med.-CJiir.  Journ.,  July  1892).  (Figs. 
80  to  83.) — This  method  has  only  a  limited  application,  bxit  is  described 
in  honour  of  its  originator.  End-to-end  union  of  divided  intestine  is 
brought  aboiit  by  invagination  aided  by  a  bone  tube.  The  method  is 
as  follows : — First  the  operator  is  prepared  with  a  decalcified  bone  tube. 


PAUL'S  METHOD  OF  EXTERORRAPIIY. 


247 


Fig.  80. 


like  that  sho^n  in  Fig.  80.  A,  to  which  is  attached  a  needle  and  a  strong- 
silk  thread,  called  the  traction-thread.  The  tube  is  required  chiefly  to 
enable  the  operator  to  produce  an  invagination  of  the  bowel  which  will 
cover  the  line  of  union ;  but  it  is  also  useful  for  keeping  open  the 
channel  of  the  intestine,  and 
as  a  splint  to  keep  the  parts 
quiet  during  the  early  stages 
of  repair. 

The  piece  of  bowel  having 
been  excised,  the  tube  is  sewn 
into  the  upper  end :  A\ith  a 
continuous  suture  of  chromic 
gut  or  silk  passing  through 
the  holes  in  the  tube  and 
taking  up  the  serous  and  mus- 
cular coats  of  the  bowel,  the 
traction-thread  is  then  passed 
through  the  wall  of  the  lower 
segment  about  three  inches 
down,  as  in  Fig.  80,  B.  Next, 
the  two  cut  ends  of  bowel  ai'e 
quickly  attached  to  each  other 
with  a  continuous  silk  suture. 
An  assistant  now  draws  firmly 
on  the  traction-thread,  Avhilst 
the  operator  produces  a  short 
invagination  which  is  retained 
in  position  b}^  three  or  four 
Lembert's  sutures  (Fig.  81, 
C,  2,  2).  Finally,  the  traction- 
thread  is  drawn  tight  and  cut 
oif  short,  its  end  dropping  into 
the  bowel. 

It  is  claimed  for  this  opera- 
tion that — (i)  the  closure  is 
absolutely  secure  as  lone;  as 
the  bone  tube  remains  intact, 
or  until  slouo-hino-  has  had 
time  to  occur ;  (2)  a  free  pas- 
sage is  at  once  established; 
(3)  the  opening  does  not  sub- 
sequently diminish  or  contract. 
The  bone  tube  is  gradually  dis- 
integrated, and  \\ill  probably 
not  be  seen  again. 

When  invaginating,  an  error 
must  be  guarded  against.  The 
invagination  is  most  easilj'  pro- 
duced by  allowing  it  to  commence  about  half  an  inch  or  so  below  the 
tube  (Fig.  83).  This  means  that  the  cut  will  be  barely  covered  by  it, 
whilst  the  lumen  of  the  bowel  will  be  considerably  blocked,  and  the 
operation  consequently  most  imperfectly  performed.     It  must  be  made 


A.  The  decalcified  bone  tube,  i,  The  lower  or 
distal  eud  perforated  for  sewing  to  the  bowel. 
2,  The  traction-thread  armed  with  long  sewing- 
ueedle.     3,  Its  attachment  to  the  tube. 

B.  A  further  stage  in  the  operation,  i,  The 
proximal  end  of  the  bowel  with  the  tube  sewn  in. 
2,  The  distal  end  not  yet  sewn  to  the  proximal, 
but  (3)  the  traction  thread  has  been  passed. 

C.  The  operation  completed,  i,  The  sheath  or 
intussuscipiens  of  the  invagination.  2,  TheLem- 
bert  sutures  for  retaining  the  parts  in  position. 

D.  The  parts,  shown  in  section,  i,  The  tube 
in  situ.  2,  The  ti-action-thread  cut  short.  3,  The 
proximal  end  of  bowel  entering  the  intussuscep- 
tion. 4,  The  distal  end  supplying  the  returning 
and  ensheathing  layers.     (Paul.) 


248 


OPERATIONS  OX  THE  ABDOMEN. 


to  commence  immediatehj  below  the  tube  hj  drawing  the  very  first  part 
of  the  lower  segment  upwards  with  the  tips  of  the  fingers  (Fig.  82), 

and  care  must  be  exercised  to  ob- 
FiG.  81.  serve  that  the  mesenteric    side    of 

the  bowel  is  as  thoroughly  covered  by 
the  invagination  as  the  other  side. 

Mr.  Paul  has  made  use  of  this 
method  with  brilliant  success  in 
two  cases  of  resection  of  gangrenous 
small  intestine  in  femoral  hernia 
[loc.  supra  cit. ;  Clin.  Soc.  Trans., 
1 892  ;  Brit.  Med.  Journ.,  vol.  i.  1 894, 
p.  235).  Mr.  Horrocks,  of  Bradford, 
has  also  used  this  method  most  suc- 
cessfully in  a  case  of  resection  of 
intestine  for  sarcoma.  About  thirty-nine  inches  were  removed,  but  the 
exact  position  is  not  given.     It  is  noteworthy  that  as  in  this  case  and 

Fig.  82. 


I,  Showing  the  cut  mesentery  improperly 
allowed  to  gape.  2,  The  mesentery  drawn 
together;  but  the  diagram  wrongly  indi- 
cates a  stitch  passing  through  tlie  bowel 
trithout  piercing  the  mesenterj-.      (Paul.) 


Fig.  83. 


Producing  the  invagination  immediaie'lij  below  the  cut.     (Paul.) 

Mr.  Paul's  second  one,  owing  to  the  dilated  condition  of  the  upper  part 
of  the  intestine,  it  would  have  been  difficult  to  invaginate  the  upper 

into  the  lower  bowel,  the  lower  was  invagi- 
nated  into  the  uj^per  without  ill  result. 

Mr.  Paul  would  only  recommend  his  method 
for  the  small  intestine,  as  most  parts  of  the 
large  are  too  fixed  to  admit  of  sufficiently 
free  manipulation  of  the  bowel. 

Absorbable  Plates. — The  following 

substances  have  been  used:  (i)  Decalcified 
Bone,  by  Prof.  Senn  ;  these  are  well  known, 
and  have  been  largely  used.  The  mode  of 
employing  them  is  given  in  detail  below, 
p.  271.  (2)  and  (3)  Turnip  and  Potato.  These  vegetable  plates 
have  been  largely  experimented  upon  in  America  and  by  a  few  Con- 
tinental surgeons — von  Baragz,  Heigl,  and  Butz — Dr.  Dawbarn,  of 
New  York,  seeming  to  have  been  the  first  to  show  exjoerimentally  that 
these  vegetable  plates  could  be  used  successfully  (^Ann.  of  Surg.,  vol.  i. 
1893,  and  Magili,  loc.  infra  cit.).  A  little  later,  but  independently, 
von  Barapz,  of  Lemberg  (Ceiitr.  f.  Chir.,  1892,  p.  575,  and  Arch.  f.  Aiin. 
Chir.,  Bd.  xliv.  S.  513-591),  published  a  series  of  experiments  and  some 
successful  cases  of  gastro-enterostomy,  in  which  plates  of  this  material 


The  iuvagination  carelessly 
produced.  The  lumen  of  the 
bowel  is  partly  closed,  and  the 
line  of  suture  barelj"  covered. 
(Paul.) 


ABSORB.\BLE  PLATES— LAPLACE'S  FORCEPS.       249 

■were  made  use  of.  "We  first  have  to  consider  the  advantages  and  disad- 
vantages common  to  all  absorbable  plates,  and  then  to  compare  the 
plates  of  decalcified  bone  with  those  of  raw  vegetable. 

When  Prof.  Seun,  to  whom  modern  surgery  owes  so  much,  introduced 
the  principle  (latest.  Sun/.,  1889),  the  following  were  the  chief  advan- 
tages claimed  :  (i)  To  save  time ;  (2)  to  do  away  with  the  evils  resulting 
from  too  many  sutures :  (3)  to  secure  a  larger  surface  of  approximation 
of  the  serous  surfaces  ;  and  (4)  to  give  complete  rest  to  the  parts  which 
it  is  intended  to  unite.* 

On  the  other  hand,  the  following  objections  have  been  brought  against 
the  decalcified  bone  plates  :  (i)  That  they  are  expensive,  tedious  to  pre- 
pare, and,  as  many  sizes  are  required  for  various  difierent  contingencies, 
they  are  not  likely  to  be  at  hand  in  an  emergency  ;t  (2)  that  the 
opening  left  is  too  small  :  (3)  that  they  require  for  their  absorption  and 
disappearance  several  days  after  they  have  ceased  to  be  needed  ;  (4)  that 
it  is  difficult  to  adjust  the  plates  with  the  right  degree  of  pressure  when 
they  are  approximated.  If  they  are  tied  too  tight  they  will  cause  pres- 
sure-sloughing of  the  serous  surfaces :  on  the  other  hand,  if  the  plates 
are  not  held  and  approximated  firmly  enough,  they  may  slide  upon  each 
other,  and  thus  cause  obstruction  of  the  opening;  (5)  it  is  not  easy  to 
return  the  bowel  and  bone  plates  unless  the  opening  into  the  abdomen 
is  a  free  one.  This  has  been  found  to  be  the  case  after  making  use  of 
them  for  intestinal  anastomosis  for  gangrenous  hernia. 

Of  Vegetable  Absorbable  Plates  I  can  say  nothing  at  first  hand, 
having  never  tested  them  or  seen  them  used.  They  are  strongly 
recommended  by  some  American  and  one  or  two  Continental  surgeons 
(p.  248),  who  claim  that  these  plates  have  all  the  advantages  of  Senn's 
bone  plates,  and  others  peculiar  to  themselves — viz. :  (i)  They  are  very 
cheap  :  (2)  they  are  always  at  hand,  being  readily  made  out  of  materials 
— turnip  or  i:)otato — which  are  easily  obtained  ;  (3)  they  quicklv  soften, 
and  are  absorbed  when  no  longer  needed ;  (4)  they  can  be  made  with  a 
large  opening. 

Laplace's  Forceps.— The  following  description  of  this  ingenious 
instrument  is  given  in  Dr.  Laplace's  own  words  (Ann.  of  Sui'i/..  March 

'^99): 

'•  The  forceps  consists  of  two  parts  which  are  really  ha?mostatic  forceps 
curved  into  a  semicircle  on  each  side  (Fig.  84) ;  onl^",  held  together  by 
means  of  a  clasp,  they  open  as  two  rings  (Fig.  85).  They  are  opened 
within  the  intestine,  and  serve  the  same  purpose  as  Senn's  rings  or  any 
other  ring  that  has  been  devised,  bringing  serous  membrane  to  serous 

*  A  useful  paper  by  Dr.  "SV.  S.  Magill,  of  Chicago,  on  the  results  obtained  by  the  use 
of  absorbable  plates,  will  be  found  in  the  Ann.  of  Surg.,  Sept.  1894.  Tables  are  given, 
and  the  writer  maintains  that  in  87  operations  there  were  only  20  deaths,  a  mortality 
of  about  23  per  cent.,  and  that  of  these  20  deaths  only  one  was  due  to  the  plates. 

t  Some  surgeons  have  found  that  the  plates  are  not  easily  preserved.  I  hardly  think 
this  fair  to  Prof.  Senu.  I  have  found  no  difficulty,  by  following  his  directions. 
Mr.  Lockwood  thus  states  his  experience  in  characteristically  terse  and  vigorous 
language  :  •■  My  own  experience  of  bone  plates  is  as  follows: — Intending  to  try  them 
upon  a  suitable  occasion,  a  bottle-full  was  obtained  from  the  instrument  maker. 
These  dried  up  and  became  hard  and  horny.  Others  were  procured,  but  they  disin- 
tegrated and  formed  a  kind  of  mud  at  the  bottom  of  the  jar"  QMcd.-Chir.  Trans., 
voL  Ixxvii.  p.  198). 


!50 


OPERATIOXS  OX  THE  ABDOMEN. 


membrane.  Accurate  suturing  is  the  operation  of  the  present.  There- 
fore if  these  forceps  are  within  the  gut  and  sutures  are  appHed,  as  they 
would  be  with  the  help  of  Senii's  rings,  it  follows  that  sutures  are  intro- 
duced all  round,  except  where  the  forceps  penetrate  the  parts  that  are 
sutured.  The  suturing  being  done,  the  foi'ceps  are  released  by  loosening 
the  clasp,  and  then  withdrawing  the  forceps  out  of  the  small  opening ; 


Fig.  84. 


Fig.  8;. 


The  haemostatic  forceps  bent  into  The  forceps  clamped  together,  and 

semicircles  and  clamp  to  hold  them        opened  as  two  rings, 
together. 

first  one  half,  then  the  other,  when  the  operation  is  finished  by  a  stitch 
or  two." 

The  forceps  may  be  used  not  only  for  circular  enterorraphy  but  also 

Fig.  86. 


End-to-snd  anastomosis.     Four  fixation  sutures  are  applied  at  the  cardinal  points, 
uniting  the  ends  to  he  approximated. 

for  lateral  anastomosis,  gaslro-enterostomy,  &c.,  the  instrument  being 
made  in  five  different  sizes.     The  advantages  claimed  ar^- :  (i  j  Rapidity 


MODIFICATIONS  OF  CIRCULAR  ENTEROERAPIIY. 


2!;i 


and  accuracy  of  suturing  without  leaving  any  foreign  substance  within 
the  gut ;  (2)  an  absolute  control  of  the  field  of  operation  by  means  of 
the  assistance  of  the  handles  of  the  forceps ;  (3)  the  facility  with  which 
the  forceps  are  applied,  preventing  the  escape  of  intestinal  contents 
during  the  operation. 

Fig.  87. 


End-to-end  anastomosis.     The  forceps  is  introduced  between  two  sutures, 
and  one  blade  is  made  to  pass  into  each  end  of  the  gut. 

End-to-End  Anastomosis  is  performed  as  follows  :  •'  Having  resected 
the  required  amount  of  intestine,  the  two  ends  are  first  united  by  a 
fixation  stitch  at  the  four  cardinal  points.     This  assures  the  right  rela- 

FiG.  88. 


End-to-eud  anastomosis.     The  forceps  is  clamped,  bringing  serous  mem- 
brane to  serous  membrane ;  sutures  have  been  applied  circularly. 


tion  of  the  mesentery  in  the  two  ends  of  the  gut. 
introduced  between  two  of  these  stitches.     The  blades 


The  forceps  are 
vre  opened  apart 


2C2 


OPEKATIONS  OX  THE  ABDOMEN. 


so  that  one  jDenetrates  one  end,  and  the  other  the  other  end.  The  serous 
surfaces  are  inverted,  or  pushed  in.  This  may  be  facilitated  by  drawing 
a  thread  around  the  united  ends  between  the  two  blades.     The  forceps 

Fig.  89. 


Eud-to-eud  auastomosis.     Oue  half  of  the  forceps  is  beiug  removed  from  small 
imsutiired  opening. 

is  clamped.  When  the  forceps  is  clamped,  serous  membrane  is  in 
apposition  to  serous  membrane.  The  svitures  are  then  applied  all 
around  the  clamped  surfaces,  to  the  point  where  the  forceps  penetrate 


Eud-to-eud  auastomosis.     The  auastomosis  is  completed. 

the  gut.     The  clamp  is  removed;  one  half  of  the  forceps  is  removed; 
the  other  half  is  then  removed.     The  operation  is  completed  by  adding 


MODIFICATIONS  OF  CIRCULAE   EXTERORR.APHY.  253 

one  or  two  stitches  to  close  the  opening  through  whicli  the  forceps 
■were  removed.'"" 

Comparison  of  Enterorraphy  with  the  Chief  Devices 

intending  to  Aid  or  Replace  it.  —  Enteronapliy  by  circular 
suturing  must  be  admitted  to  be  the  ideal  operation  from  its  simplicity, 
the  entire  absence  of  any  especial  apparatus,  and  the  fact  that  no  foreign 
body  is  left  behind  which  may  perhaps  give  trouble  ere  it  come  away. 
Those  who  condemn  it  as  unsuccessful  must  remember  (i)  that  it  has 
been  gradually  and  slowly  perfected,  being  often  laid  aside  for  some 
new  device  and  then  resorted  to  again,  and  that  it  Avas  very  largely 
used  in  the  earlier  and  darker  days  of  intestinal  surgerj- ;  (2)  that  when 
used  by  skilled  hands  it  has  proved  most  effective  and  reliable  in  the 
time  of  emergency.*  When  used  by  such  hands — and  it  is  one  advan- 
tage of  this  method  that  it  is  easy  for  any  operating  surgeon  to  acquire 
skill  in  it — care  will  be  taken  to  fulfil  the  conditions  necessary  for 
successful  enterorraphy,  viz. :  (a)  sufficient  inversion  of  the  serous 
coats ;  (/>)  sufficient  penetration  of  the  coats  without  perforation  of  the 
lumen  of  the  intestine ;  (e)  careful  adjustment  of  the  junction  of  the 
intestine  and  the  mesentery  (Figs.  59,  97.  99).  and  (<^)  placing  of 
the  sutures  in  healthy  tissues. 

It  is  right  to  state  clearly  here  that  many  excellent  judges,  men  well 
experienced  in  intestinal  surgery,  condemn  circular  enterorraphy.  Thus 
Dr.  A.  B.  Robinson  (Ann.  of  »S'w7v/.,  vol.  i.  189 1,  p.  430)  states  that  he 
found  it,  from  experiments  on  dogs,  very  dangerous,  for  the  following 
reasons  :  (i)  It  pai-alyses  the  gut.  and  hence  does  not  so  readily  relieve 
the  fascal  obstruction  which  is  the  immediate  object  of  surgical  inter- 
ference. To  this  it  may  be  replied  that,  as  shown  at  p.  257.  the  joining  of 
ends  of  intestine  resected  while  obstruction  is  present  should  be  deferred 
whenever  possible  ;  and  when  this  is  not  possible — a  rare  contingency — 
the  intestines  should  be  thoroughly  emptied  before  they  are  resected. 
If  this  is  not  practicable,  union  should  be  deferred  and  drainage  con- 
tinued by  Paul's  tubes  (Fig.  54,  &c.).  (2)  A  ftecal  fistula  is  apt  to  arise 
at  the  point  of  suture.  (3)  Gangrene  or  sloughing  may  arise  from  the 
pi'essure  of  numerous  sutures.  These  are  very  fair  criticisms.  They 
must  each  be  met  by  care  in  suturing,  and  by  attention  to  the  junction 
of  the  intestine  and  the  mesentery.  (4)  The  lumen  of  the  two  ends  may 
be  unequal.  When  this  difficulty  is  marked,  circular  enterorraphy  must 
be  abandoned  for  intestinal  anastomosis.  (5)  Pathological  changes  due 
to  obstruction  in  the  bowel  may  offer  impediments.  The  gut  may  be 
stretched  so  thin  that  a  needle  cannot  be  passed  between  the  muscular 
and  mucous  layers  without  danger  of  penetrating  the  mucous  layer  and 
causing  faecal  fistula.  I  have  pointed  out  elsewhere  (p.  257)  that  union 
of  resected  intestine  is  not  to  be  attempted  where  obstruction,  over- 
distension. &c.,  are  present.  Where  the  distension  has  been  prolonged, 
as  in  malignant  disease  low  down  in  the  canal,  circular  enterorraphy  is 
contra-indicated.  This  is  not  the  case  where  the  obstruction  has  been 
of  shorter   duration — e.;/..   in    gangrenous   herniee — as    shown    by   the 

*  To  mention  a  few  cases  only,  I  refer  my  reader  to  those  of  Mr.  Lockwood  and  to 
Dr.  McCosh's  four  successful  cases  of  circular  enterorraphy  after  resection  of  small 
intestine  for  gangrene.  To  such  urgent  emergencies,  circular  enterorraphy  is  especially 
suited  if  the  surgeon  has  had  sufficient  practice  to  rely  on  himself. 


254  OPERATIONS  ON  THE  ABDOMEN. 

successfvil  cases  given  at  p.  262.  (6)  Circular  stricture  followed  the 
experiments.  Some  of  the  strictures  were  so  severe  that  both  fseces  and 
gas  were  actually  obstructed.  (7)  The  long  time  required  for  a  circular 
enterorrapl\v  militates  against  the  chances  of  recovery.  Of  all  surgery 
in  the  world,  intestinal  surgery  should  be  rapid  and  skilful.  Of  the 
diflferent  methods,  Dr.  Robinson  recommends  Lembert's  sutures,  making 
these  continuous  for  two,  three,  or  four  stitches.  This  worked  well  and 
saved  time,  three  to  five  interruptions  of  Lembert's  sutures  completing 
the  circle  round  the  gut.  In  this  wa}!"  a  circular  enterorraphy  can  be 
completed  in  less  than  half  an  hour.  Dr.  Robinson  emphaticali}^  opposes 
a  circular  enterorraphy  with  a  continuous  Lembert's  suture.  "  This  was 
carefulh*  tried,  and  the  worst  strictures  of  all  resulted ;  not  only  that, 
but  the  thread  gradually  fell  into  the  gut  lumen,  and  its  end  dangled 
for  days  and  even  weeks  there  before  it  became  entirely  set  free.  This 
long  thread  will  certainl}'  be  a  dangerous  source  of  infection,  as  infective 
fluids  can  go  along  it  by  mere  capillary  attraction,  not  to  speak  of  the 
wider  fgecal  fistula  it  may  create."  There  is  much  weight  in  these  last 
twp  criticisms.  An  increasing  number  of  recent  successful  cases  of 
circular  enterorraphy,  amongst  these  being  one  by  Lockwood  (p.  262), 
three  by  McCosh  (p.  262),  one  by  Ransohofi"  (p.  262),  and  many  by  Con- 
tinental surgeons,  show,  however,  that  they  are  not  unanswerable. 

Messrs.  Ballance  and  Edmunds  (Trans.  Med.-CJdr.  Soc,  1896)  have 
carried  out  an  experimental  enquiry  with  especial  reference  to  the 
question  of  the  best  means  of  uniting  resected  intestine.  The  following, 
very  briefly  put,  are  some  of  the  conclusions  to  which  the  authors  were 
led  with  regard  to  enterorraph}',  and  other  methods  of  resecting  intestine. 
With  regard  to  end-to-end  union,  the  above-mentioned  authors  prefer 
simple  suturing  to  the  use  of  any  form  of  supporting  apparatus.  They 
recommend  either  the  Czerny-Lembert  or  Maunsell's  method.  Of  five 
experiments  on  dogs  performed  by  the  former,  and  two  by  the  latter 
method,  all  did  well.  With  regard  to  the  Czern5^-Lembert  method, 
emphasis  is  laid  on  the  care  needed  at  the  mesenteric  junction  and  on 
the  following  facts.  In  the  small  intestine  eversion  of  the  mucous 
membrane  takes  place  to  such  a  marked  degree  that  the  insertion  of  the 
inner  row  of  sutures  only  results  in  apposition  of  mucous  membrane  to 
mucous  membrane.  Thus  the  integrity  of  the  junction  depends  solely 
on  the  Lembert  sutures.  The  result  of  the  inversion  produced  by  these 
is  a  ridge  which  remains  at  the  line  of  junction,  sometimes  seriously 
contracting  the  lumen  of  the  gut.  This  untoward  result  is  especialty 
likely  to  be  brought  about  if  the  surgeon  is  uncertain  about  the  efficiency 
of  his  row  of  Lembert's  sutures,  and  is  tempted  to  put  in  others,  still 
further  diminishing  the  lumen  of  the  bowel.  The  above  objection  does 
not  apply  to  Maunsell's  method,  which  produces  very  perfect  union, 
mucous  coat  being  united  to  mucous,  muscular  to  muscular,  and  serous 
to  serous.  After  the  Czerny-Lembert  method  a  circular  ridge  or 
diaphragm  is  always  to  be  found  on  laying  open  the  intestine.  This  is 
not  so  after  the  Maunsell  method :  here  it  is  quite  difficult  to  recognise 
the  line  of  circular  junction,  this  presenting  a  marked  contrast  with 
the  ridge  seen  at  the  site  of  the  longitudinal  incision  which  had  been 
closed  by  Lembert's  sutures. 

Of  the  different  methods  of  producing  lateral  anastomosis,  Mr. 
Ballance  and  Mr.  Edmunds  consider  Halsted's  (Figs.  106  to  108)  to  be 


MODIFICATIONS  OF  CIRCULAR  ENTERORRAPHY.  255 

superior  to  all  in  which  plates,  bobbins,  and  other  mechanical  aids  are 
used.  The  above-mentioned  authorities  emphasise  one  objection  which 
applies  to  all  of  the  above — viz.,  that  the  surgeon  may  very  likel}',  in 
cases  of  emergency,  not  be  provided  with  the  size  he  requires.  As  to 
the  claim  that  such  devices  shorten  the  time  of  operation,  Messrs. 
Ballance  and  Edmunds  reply:  (i)  That  if,  as  in  Senn's  method  of 
anastomosis,  sutures  have  to  be  placed  around  the  plates,  the  time 
taken  is  not  much  shortened.  (2)  Such  a  method  as  Halsted's  lateral 
anastomosis  does  not  take  long  if  proper  attention  is  paid  to  the 
following  essentials  :  (a)  A  plentiful  supply  of  round  needles  read}' 
threaded  with  silk  sufficiently  thick  not  to  cut  the  intestinal  coats. 
(/3)  Using  the  needles  as  sjDlints.  Thus,  if,  just  as  one  thread  is  coming 
to  an  end,  the  needle  which  carries  it  be  left  in  situ  transfixing  the  cut 
edges,  this  will  keep  the  parts  together  and  greatly  facilitate  the  intro- 
duction of  the  next  suture. 

It  is  becoming  increasingly  clear,  I  think,  that,  in  the  hands  of  an 
operating  surgeon  who  has  taken  care  to  acquire  skill  by  practice,  the 
chief  objections  to  enterorraphy  will  be  very  greatly  reduced — viz.,  the 
time  taken,  the  number  of  sutures  needed,  the  risk  of  perforating  the 
lumen  of  the  gut,  of  leakage  at  the  junction  of  mesentery  and  intestine, 
a,nd  of  stenosis  from  contraction  of  the  cicatrix,  especially  if  the  inver- 
sion has  been  needlessly  free. 

Where  the  surgeon,  from  any  want  of  faith  in  his  skill,  or  from  the 
condition  of  the  patient  requiring  that  the  operation  should  be  com- 
pleted speedil}-,  prefers  to  rely  upon  one  of  the  devices  intended  to  aid 
or  to  replace  circular  enterorraphy,  he  will  be  wisest  in  making  use  of 
Murphy's  button  or  Mayo  Robson's  bobbin.  Of  these  Murphy's  button 
is  highly  to  be  recommended  on  account  of  the  rapidity  with  which  the 
operation  can  be  completed.  For  although  there  are  undoubted  objec- 
tions to  the  use  of  the  button,  as  above  described,  careful  adjustment  in 
well-nourished  intestine,  and  a  wise  selection  in  choosing  the  size  of 
button  to  be  used,  ^^■ill  avoid  most  of  them.  Moreover,  it  must  be 
remembered  that  the  accidents  that  have  happened  are  comparative!}' 
rare,  and  the  results,  as  far  as  can  be  judged,  are  on  the  whole  satisfac- 
tory. Comparison  between  Murphj-'s  button  and  other  methods  of 
resection  in  the  series  of  226  cases  of  resection  of  intestine  for  gan- 
grenous hernia  collected  by  Gibson  (Ann.  of  Siiri/.,  Nov.  1900)  is  on 
the  whole  to  the  advantage  of  the  Murphy  button  :  for  in  the  63  cases 
in  which  Murph}-'s  button  was  used  there  were  14  deaths,  i.e..  a  mortalit}- 
of  22  per  cent.,  while  in  the  remaining  163  cases  in  which  various 
other  methods  were  made  use  of  there  were  44  deaths,  or  a  mortality  of 
27  per  cent. 

Moreover.  Sir  F.  Treves  (Brit.  Med.  Journ.,  Aug.  28.  1S98)  considers 
that  the  ^Murphy  button  is  the  best  means  of  uniting  divided  intestine, 
having  employed  it  in  fifty  cases  with  satisfactory  results. 

Mayo  Robson's  bobbin,  by  giving  support,  facilitates  the  suturing  at 
the  time  and  supplies  some  of  the  conditions  which  are  at  the  root  of 
Senn's  excellent  principle — viz.,  the  giving  support  to  the  ends  of  the 
intestine  by  a  body  which  ^^  ill  be  safely  absorbed.  From  its  shape,  and 
its  simplicity  in  the  absence  of  threads.  I  consider  this  bobbin  more 
easily  inserted  and  used  in  effecting  a  direct  junction  of  the  ends  than 
Prof.  Senn's  plates  and  lateral  anastomosis,  ^\■hile  its  ready  applicability 


256  OPERATIONS  OX  THE   ABDOMEN. 

to  a  very  large  range  of  different  operations  puts  it,  in  my  opinion, 
on  an  equal  footing  with  Murphy's  button.  Moreover,  the  part  it  is 
intended  to  play,  and  the  material  of  A^hich  it  is  made,  render  it  far 
safer  than  that  most  ingenious  device. 

The  same  absence  of  any  threads  to  tie,  and  its  wider  applicability, 
make  Mr.  Robson's  bobbin  superior  to  Mr.  Paul's  decalcified  bone  tube, 
though,  as  I  have  stated  at  p.  248,  several  successful  cases  prove  the 
efficiency  of  this  device. 

The  choice  may  be  said,  therefore,  to  lie  between  direct  suture  or 
Maunsell's  method.  Murphy's  button,  and  Mayo  Robson's  bobbin. 
Which  of  these  methods  will  be  fi)ially  judged  to  be  the  best  is  still 
uncertain. 


RESECTION     OF    INTESTINE.       ENTERECTOMY. 
COLECTOMY. 

Indications  for  Resection  Operations.  —  The  chief  of  these  are: 
(i)  New  growths.  (2)  Gangrene  after  strangulation  in  hernia  or 
intestinal  obstruction.  (3J  Injuries,  gunshot  or  otherwise.  (4)  Some 
cases  of  irreducible  intussusception.  (5)  Some  cases  of  artificial  anus 
where  the  canal  of  the  intestine  cannot  be  otherwise  restored. 

I  propose  to  say  a  few  words  about  the  first  two,  the  most  frequent  of 
the  above  indications. 

The  subject  of  Resection  for  Gunshot  and  other  Injuries  is  fully  dealt 
with  in  the  next  chapter. 

(i.)  Indications  for  Resection  in  New  Growths. — In  deciding 
between  resection  and  one  of  the  forms  of  anastomosis  without  resection, 
or  between  resection  and  artificial  anus,  the  surgeon  should  pay  parti- 
cular attention  to  the  following  points,  both  local  and  general.  The 
more  they  are  present,  the  more  favourable  is  the  case.  Small  size, 
definite  outline,  especially  if  the  growth  approaches  the  annular  form, 
free  mobility  as  pointing  to  absence  of  adhesions,  entire  absence  of 
that  tenderness  which  points  to  peritonitis,  or  even  to  that  breaking- 
down  and  suppuration  which  may  accompany  new  growths  when  they 
ulcerate  and  become  septic,  a  situation  in  which  the  growth  can  be 
easily  got  at  and  isolated,  e.r/.,  when  it  attacks  a  portion  of  intestine 
with  a  long  mesentery,  and  not  a  fixed  part  such  as  the  splenic  or 
hepatic  flexure.*     These  are  the  chief  local  points. 

Amongst  the  general  points  that  must  weigh  with  the  operator  are 
the  strength  and  nutrition  of  the  patients,  their  fitness  to  bear  a  severe 
operation  and  to  supply  the  needful  plastic  repair. 

Another  point  having  a  most  important  bearing  upon  the  advisability 
of  performing  resection  for  malignant  disease  is  whether  this  is  compli- 

*  In  the  tables  of  Weir  (iVlvr  York  Med.  Journ..  Feb.  13,  1886)  ;  Butlin  (_Oper.  Surg,  of 
Maliff.  J)is.,  p.  231),  of  the  37  cases  collected  in  which  resection  of  cancerous  bowel 
was  performed,  32  were  of  the  large  intestine.  The  parts  involved  were — caecum,  7  ; 
ascending  colon,  4 ;  transverse  colon,  3 ;  descending  colon,  7 ;  sigmoid  flexure,  9  j 
"  colon,"  2.  Malignant  disease  is  so  frequent  in  two  regions,  the  ileo-Cfecal  and  the  left 
iliac  fossa,  that  when  there  is  any  reason  to  suspect  it  an  early  exploratory  incision 
should  always  be  made. 


EESECTION  OF  INTESTINE,   ETC.  257 

cated  by  obstruction,  tympanites,  &c.  If  there  is  one  point  which 
published  (and  still  more  the  unpublished*)  cases  prove,  it  is  that  the 
occasion  in  which  it  is  right  to  submit  a  patient  the  subject  of  intestinal 
obstruction  to  such  a  prolonged  operation  as  resection  and  suture  or 
anastomosis  of  the  resected  parts  must  be  of  the  very  rarest. f  This  is 
plain  from  the  usual  state  of  the  patient  in  these  cases,  and  the  condi- 
tions within  the  abdomen  with  ^^■hich  the  operator  has  to  deal.  Is  a 
patient,  usually  past  middle  life,  whose  strength  and  powers  have  been 
sapped  for  daj^s  or  weeks  by  the  nausea,  inability  to  take  food,  vomiting, 
distension,  and  all  the  distress  which  forms  part  of  a  miserere  of  the 
later  stages  of  chronic  intestinal  obstruction,  in  a  fit  state  to  go  through 
a  prolonged  operation,  and  to  supply  after  it  the  plastic  repair  which  is 
needful  for  success  ?  There  can  he  but  one  answer  here.  And  it  is  the 
same  when  we  examine  those  local  conditions  which  will  have  to  be  faced 
by  the  operator.  The  distension  of  the  intestines,  and  the  difficulty 
of  keeping  them  within  the  belly,  prolong  the  operation,  add  to  the 
shock  in  an  exhausted  patient,  and,  by  rendering  asepsis  most  difficult, 
diminish  his  chances  still  further.  Another  point,  viz.,  the  condition 
of  the  intestine  above  and  below  the  obstruction,  is  a  strong  argument 
against  resection  and  union  of  the  intestine  when  obstruction  is  present. 
Above,  the  intestine  will  be  distended,  congested,  softened  ;  below,  empty 
and  shrunken.  The  difference  in  the  size  of  the  two  sections  may  jDrove 
a  serious  difficulty  in  their  union,  but  a  graver  objection  to  uniting 
them  now  is  the  fact  that  for  the  present  both  are  paral^'sed ;  and 
though  this  can  be  met,  in  a  measure,  by  emptying  the  contents  of  the 
irpper  bowel  when  this  is  cut  through  above  the  growth,  yet  everyone 
familiar  with  these  cases  knows  perfectly  well  that  if  the  obstruction  be 
low  down  it  is  extremely  difficidt  to  empty  the  bowel  above  sufficiently 
in  the  short  time  available.  Much  of  its  contents  are  left  behind ;  the 
condition  of  obstruction  largely  continues,  with  its  result — a  con- 
tinuance of  toxic  absorption  ;  and  if  the  contents  of  the  intestine  are 
passed  on  from  above,  too  often  they  find  the  junction  of  the  resected 
parts,  made  in  softened,  inflamed  tissues,  unfit  to  bear  the  strain. 
Where  obstruction  is  present,  resection  should  be  deferred  until  one  of 
following  steps  has  been  adopted.  Colotomy  may  be  performed  in 
the  ca?cum  or  some  pai't  of  the  colon,  to  empty  the  intestine  and  restore 
its  tone,  while  at  the  same  time  the  patient's  strength  is  restored,  and 
the  surgeon  chooses  his  OAvn  time  for  the  performance  of  what  is  a  very 
severe  operation.  Another  way  of  performing  resection  in  two  stages 
is  that  advocated  by  Mr.  F.  T.  Paul.:!:  whose  name  will  frecjuently  occur 
ill  these  pages,  as  an  authority  in  abdominal  surgery.     The  following 


*  Quite  as  instructive  in  their  Avay.     ••  Nee  silet  mors." 

t  Dr.  Eicketts  QAfin.  of  Surg.,  vol.  i.  1894,  p.  472)  relates  a  case  which  was  most 
favourable  for  resectiou.  The  growth,  only  of  the  size  of  a  hickory  nut,  was  easily 
found,  drawn  out,  and  resected.  The  ends  were  united  by  a  Murphy's  button.  The 
ileum  being  enormously  distended  with  faecal  fluid,  owing  to  the  patient  having 
deferred  operation  till  the  last,  about  a  gallon  was  withdrawn  by  an  incision,  which 
was  closed  by  Lembert's  suture.     The  patient  sank  ten  hours  later. 

\  ••  Colectomy  "  {Brit.  Med.  Journ.,  vol.  i.  1895,  p.  1136).     A  paper  full  of  practical 
information,  but  especially  noteworthy  and  admirable,  nowadaj-s,  from  its  convincing 
candour.     Failures  are  related  as  well  as  successes,  and  are  equally  instructive. 
VOL.   II.  17 


258 


OPERATIO^'S  ON  THE  ABDOMEN. 


Fig.   91. 


are  the  chief  steps  of  this  operation,  i.  Explore  first  in  the  middle 
line  unless  the  site  of  the  obstruction  is  known.  2.  Make  a  sufficiently 
free  incision  over  the  site  of  the  obstruction.  3.  Having  cleared 
away  any  adhesions,  tie  the  mesenter}',  and  divide  it  sufficiently  to 
free  the  bowel  well  beyond  the  growth  on  each  side.  4.  Let  the 
loop  of  bowel  containing  the  growth  or  stricture  hang  out  of  the 
abdomen,  and  sew  together  the  mesentery  and  the  adjacent  sides  of 
the  two  ends  (Fig.  91).  See  that  the  stump  of  mesentery  lies  beneath 
the  bowel,  where,  if  deemed  advisable,  it  can  be  drained  by  packing- 
cyanide  gauze  down  to  it. 
5.  Ligature  lightly  a  glass 
intestinal  drainage-tube 
(Figs.  54  and  91)  into  the 
bowel  above  and  below 
the  obstruction,  and  then 
cut  awa}^  the  affected  part. 
When  the  operation  is  thus 
performed,  all  the  vessels 
except  those  in  the  primarj^ 
incision  are  tied  before  they 
are  cut,  and  the  intra-peri- 
tongeal  work  is  rendered 
bloodless.  6.  The  second 
stage  of  the  operation — that 
of  destroy  ing  the  spur  which , 
as  will  be  gathered  from 
Fig.  91,  is  formed  by  the 
above  operation — is  under- 
taken about  three  weeks 
later.  A  finger  being  intro- 
duced into  the  bowel,  as  a 
guide  to  each  side  of  the 
spur,  dressing-forceps  with 
the  handles  fastened  to- 
gether by  india-rubber  tub- 
ing, or  appropriate  clamp- 
forceps,  are  applied  to  the 
spur,  one  blade  on  each  side. 
These  will  come  away  with- 
in a  week,  and  some  days 
later  the  rest  of  the  spur  is 
destroyed  in  like  fashion,  the  forceps  being  now  applied  as  far  as  the 
finger  makes  out  the  spur  to  reach.  As  soon  as  this  is  satisfactorily 
accomplished  the  artificial  anus  is  closed  b}'  separating  the  rosette  of 
mucous  membrane  from  the  skin,  turning  it  in,  and  bringing  the 
freshened   edge  of  the  latter  over  it. 

Another  method  is  to  get  the  affected  coil  outside  ;  if  this  be  not 
too  tied  down  by  adhesions,  keep  it  so  b}^  means  of  a  rod  passed 
beneath  it,  a  Paul's  tube  being  then  tied  into  the  uj^per  end  to  drain 
it.  Some  days  later,  when  the  patient's  condition  admits  of  it,  the 
growth  is  resected,  and  the  two  ends  united.  Mr.  Lane  adopted  this 
plan    successfully  in   a   very  interesting   case  of  growth  of  the  lower 


Colectomy  by  Paul's  method.  Drainage  of  the  bowel, 
aud  prepai-atiou  of  it  for  subsequent  safe  resection  of 
the  bowel.     (Paul.) 


RESECTIOX  OF  IXTESTIXE.   ETC. 


259 


part  of  the  ileum.  A  knitting-needle  covered  with  india-rubber 
tubing  was  employed  here  to  keep  the  bowel  outside  (Clin.  Soc. 
Trans.,  vol.  xxvi.  p.  40). 

Operation. — The  first  question  which  arises  is  as  to  the  best  incision. 
If  the  surgeon  is  uncertain  as  to  the  exact  site  of  the  growth,  he  may 
make  a  median  incision  and  clear  the  matter  up :  other^^•ise  the  incision 
should  be  made  over  the  growth  itself,  either  horizontally,  as  in  an  incision 
for  appendicitis  or  for  left-sided  inguinal  colotomy.  or  vertically,  or  in 
one  linea  semilunaris.  The  variety  of  the  incision  is  immaterial  as  long 
as  the  growth  and  the  intestine  entering  and  leaving  it  is  thoroughly 
exposed.  That  the  median  incision  is  not  best  suited  for  this  is  shown 
by  the  number  of  cases  recorded  in  which,  after  the  operator  had  begun 
by  an  incision  in  the  linea  alba,  he  abandoned  it,  as  inade- 
quate, for  one  over  the  gro^\i:h.  The  growth,  when  reached,  Fig.  92. 
may  be  covered  by  adherent  omentum,  or  resemble  an 
intussusception,  appearing  as  a  thick  rounded,  firm,  sausage- 
like swelling.  When  the  gi-OA%i:h  is  fully  exposed  the 
surgeon  settles  whether  to  attempt  resection  or  to  perform 
a  lateral  anastomosis  (p.  268).  Resection  being  decided 
upon,  the  field  of  operation  is  carefully  shut  off  from 
the  genei"al  peritona?al  sac  by  sterile  gauze.  I  shall  first 
describe  a  comparatively  simple  case — e.g.,  resection  of  a 
limited  gro\\-th  of  the  small  intestine  or  sigmoid,  and,  later, 
the  more  difficult  removal  of  the  ileo-C£ecal  coil.  Any 
adhesions  present  must  next  be  divided  with  a  blunt- 
pointed  scissors  or  a  dissecting  tool  (Fig.  92).  The 
difficulty  met  with  here  varies  extremely.  The  adhesions 
may  be  so  dense  as  to  render  further  operation  impossible. 
In  such  a  case  short-circuiting  should  be  performed. 
Omental  adhesions  are  not  uncommon — i.e.,  to  the  parietes, 
over  the  growth  or  adhesions  between  the  omentum,  and  the 
small  and  large  intestine  contiguous  to  the  growth.  The 
loop  having  been  freed  is  brought  outside  the  wound,  placed 
upon  gauze,  and  emptied  by  gentle  pressure  with  the  fingers 
in  both  directions.  This  effected,  clamps  are  applied  well 
above  and  below  the  spots  where  it  is  decided  to  divide  the  (Down's  Cata 
intestine  (vide  p.  261).  A  host  of  such  instruments  have  logue,  1894.) 
been  devised.  The  best  are  those  of  Prof.  Kocher  (Fig.  93) 
and  Mr.  Makins  {St.  Thomas's  Hosp.  Be^'.,  1884,  p.  81)  (Fig.  94).  The 
former  will  be  found  extremely  useful  on  account  of  the  handles,  by 
means  of  which  the  steps  of  the  operation  are  gi'eatly  facilitated.  Mr. 
^lakins's  have  the  advantage  that  the  compression  exercised  can  be 
more  accurately  adjusted  by  means  of  a  screw. 

Several  other  clamps  act  by  perforation  of  the  mesentery.  One  of 
the  simplest  of  these  is  the  plan  devised  by  the  late  Dr.  Maunsell 
{Amer.  Journ.  Med.  Sci.,  March  1892).*  A  flat  piece  of  sponge  is 
])laced  over  the  bowel,  about  four  or  six  inches  from  the  part  to  be 
excised,  and  the  sponge  and  the  mesentery  close  to  the  gut  are  then 


Mr.  Watson 

Chevue's    fine 

dissector. 


*  The  late  Dr.  Mauusell,  writing  of  Neuber's  method  (loc.  svpra  eit.),  says  :  "  I  have 
tried  this  method  and  found  that  the  bowel  may  be  injured  by  the  ligature,  no  matter 
what  care  may  be  taken  in  applying  it." 


26o 


OPERATIONS  OX  THE  ABDOMEN. 


transfixed  with  a  strong  safety-pin.  The  pin  is  again  passed  through  the 
sponge  on  the  other  side  of  the  gut  and  clamped.  The  sponge  should  be 
large  enough  to  compress  the  intestine  against  the  pin,  so  as  to  effec- 
tually prevent  extravasation.  The  advantages  claimed  "  are  its  extreme 
simplicity,  its  easy  applicability,  its  innocuousness,  and  its  efficiency."' 
The  pressure  can  be  regulated  by  the  size  of  the  sponge.     Another  very 

Fig.  93 


Resection  of  intestine,  showing  Koeher's  clamps  applied.      The  clamps  should  have 
been  placed  obliquely  along  the  Hues  x  x  to  ensure  a  good  lilood-supply.   (Kocher.) 

simple  method  is  that  of  Neuber,  in  which  a  narrow  elastic  band*  is 
]mssed  through  a  small  opening  made  in  the  mesentery,  close  to  the 
intestine,  and  tied  or  clamped  around  the  gut.  Others  have  used  cords 
of  gauze.  Fig.  95  shows  a  clamp  devised  on  the  same  principle  by 
Mr.  W.  A.  Lane.     In  using  any  clamp  which  perforates  the  mesentery, 

Fig,  94. 


Mr.  Makins's  clamp-forceps,  for  use  in  resection  of  intestine.    This  and  tlie  next 
clamp  should  be  covered  v/ith  india-rubber. 

great  care  must  be  taken  not  to  injure  any  vessel.  This  is  easily 
managed  in  the  case  of  undistended  intestine,  but  when  obstruction  is 
present  and  all  the  small  vessels  enlarged,  very  troublesome  bleeding- 
may  follow  perforation  of  the  mesentery. 

Whatever  form  of  clamp  is  used,  if  it  has  been  long  in  situ,  it  ma}^  be 


KESECTIOX   OF  INTESTINE,   ETC.  261 

well  to  shift  it,  and  to  cut  away  the  ends  of  the  intestine  which 
have  been  submitted  to  pressure,  for  fear  that  their  nutrition  has 
suffered  dangeroush'. 

"Where  no  clamps  are  obtainable  an  assistant's  hands  must  be  made 
use  of.  But  clamps  are  much  to  be  preferred ;  hands  are  more  in  the 
way,  and,  however  willing,  are  liable  to  make  more  varying  pressure, 
and  to  relax  long  before  a  tedious  operation  is  completed. 

If  the  intestine  is  at  all  distended,*  it  is  emptied  in  the  manner 
advised  at  footnote  p.  265.  The  diseased  mass  is  now  resected  Avith 
blunt-pointed  scissors,  the  gut  being  cut  across  at  right  angles  to  its  long 
axis  quite  three-quarters  of  an  inch  beyond  the  growth.  This  should 
leave  about  two  inches  of  gut  beyond  each  clamp,  in  order  to  allow  of 

Fic.  95. 


Lane's  intestinal  clamp.     (Down's  Catalogue,  1894.) 

the  introduction  of  a  Murphy's  button  or  a  bobbin.  As  a  rule,  the 
section  of  the  intestine  should  be  made  at  right  angles  to  its  long  axis, 
and,  in  the  present  instance,  resection  of  intestine  for  growtli,  the  inci- 
sions should  be  carried  onwards  through  the  mesentery  so  as  to  remove 
a  triangular  piece- with  the  base  below  at  the  intestine.  By  this  means 
it  is  possible  that  implicated  lymphatics  will  be  removed  as  well.  The 
cut  vessels  in  the  mesentery  are  either  clamped  and  tied  with  catgut,  or, 
where  a  large  piece  has  to  be  removed,  they  can  be  secured  before,  and 
haemorrhage  avoided,  by  means  of  an  aneurysm-needle  carrying  catgut. 

Another,  but  in  the  case  of  growth  less  desirable,  way  of  treating  the 
mesentery  is  given  below  (Figs.  97,  98).  In  either  case  any  enlarged 
glands  are  now  removed.  The  soiled  gauze  which  has  shut  off  the  field 
of  operation  is  next  replaced  by  fresh,  and  the  surgeon  decides  whether 
to  unite  the  intestine  by  direct  suture,  by  Murphy's  button,  or  Robson  s 
bobbin,  or  to  perform  anastomosis  of  the  two  parts  of  the  intestine  by 
Senn's  plates,  Murphy's  button,  or  Eobson's  bobbin. 

AYith  regard  to  the  details  of  the  steps  adopted  in  the  more  difficult 
operation  of  resection  of  the  ileo-ca?cal  coil.  I  shall  quote  from  a  very 
hel|)ful  report  of  a  case  bv  Mr.  Lowson,  of  Hull  (^Lancet,  vol.  i.  1893, 
p.  618): 

The  abdomen  liaviug  been  opened  by  an  incision  in  the  right  linea  semilunaris,  the 
omentum  was  found  aiLliereut  to  the  tumour  anteriorly,  and  detached  after  ligature. 
'•  Pushing  the  colon  inwards."  I  now  entered  the  scissors  above  the  level  of  the  tumoar, 
through  the  peritonieum  lining  the  posterior  wall  of  the  abdomen,  to  the  outer  side  of 

*  After  emptying  the  intestine  there  may  still  remain  much  difference  between  the 
ends  when  resected.  Either  the  upper  segment  must  be  partialis'  closed  by  a  continuous 
and  Lembert's  sutures  until  the  part  left  patent  corresponds  to  the  lumen  of  the 
collai)sed  bowel  below,  a  step  successfully  ailoptcd  by  Sir  F.  Treves  QLancct,  vol.  i.  1893, 
p.  522),  or  both  ends  must  be  closed  and  a  lateral  anastomosis  emploj'ed  (p.  268). 


262  OPERATIONS  OX  THE  ABDOMEN. 

the  great  bowel,  and  ran  it  down  to  a  point  opposite  the  lower  end  of  the  caecum.  The 
bowel  could  now  be  easily  separated  from  its  bed.  It  still  remained  to  divide  the 
peritonaeum  on  the  inner  side  where  the  colic  vessels  spread  out.  fan-like,  to  supply  the 
colon.  This  was  done  by  tying  the  serous  membrane  with  the  vessels  in  five  or  six 
successive  pieces,  and  dividing  between  the  ligatures  and  colon.  The  line  of  this 
incision  inclined  downwards  and  inwards,  meeting  the  ileum  as  it  crossed  to  join 
the  colon  five  or  sis  inches  from  the  ileo-cffical  valve.  Several  diseased  glands  were 
included  in  this  triangle.  The  ileum  was  separated  from  the  mesentery  in  the  same 
way.  and  now  the  greater  part  of  the  ascending  colon,  with  the  csecum  and  four  or  five 
inches  of  the  ileum,  were  free  along  with  the  tumour.  The  time  had  now  arrived  for 
dividing  the  bowel.  Two  long  Makins's  clamps  were  applied  to  the  colon  above  the 
tumour,  and  between  these  the  bowel  was  divided  as  nearly  at  right  angles  as  possible. 
The  ileum  having  been  divided,  and  the  diseased  portions  removed,  the  ends  of  the 
intestine  were  closed  by  fine  continuous  sutures  and  turned  in  by  Lembert's  sutures. 
Lateral  anastomosis  was  performed  by  means  of  Senn's  plates.  Mr.  Lowson  draws 
attention  to  one  detail,  which,  as  he  says,  "  cannot  be  neglected  without  fatal  extrava- 
sation— i.e..  to  be  especially  particular  to  bring  the  serous  surfaces  accurately  in 
apposition  at  the  point  where  the  mesentery  joins  the  intestine,  and  where  the  serous 
coat  of  the  mesentery  is  deficient  behind."  The  patient,  aged  33.  made  a  good  recovery, 
and  thirteen  months  later  there  was  no  perceptible  recurrence. 

(ii)  Resection  of  Intestine  for  Gangrenous  Hernia.* — This,  the 
second  most  frequent  indication  for  resection,  must  be  treated  separately. 
The  operation  has  now  to  be  undertaken  under  different  conditions  from 
that  under  wliich  removal  of  a  new  growth  is  performed.  We  have  seen 
(p.  257)  that  then  it  is  always  best  to  defer  resection  of  the  intestine,  if 
possible,  until  obstruction  has  passed  away  under  medical  treatment,  or 
has  been  met  by  a  colotomy,  the  surgeon  choosing  his  time  when  the 
patient's  general  condition  of  strength  and  nutrition,  and  the  local  state 
of  the  bowel,  are  alike  rendered  as  favourable  as  may  be  for  meeting  the 
calls  of  a  severe  plastic  operation.  In  resection  for  gangrenous  hernia, 
the  conditions  both  of  the  patient  and  the  intestine  to  be  operated  on 
are  ver}^  different.  Before  describing  the  acttial  operation  I  would  say 
that  no  absolute  rules  can  be  laid  down  here.  Eelief  of  a  strangulated 
hernia  is  one  of  those  operations  of  emergency,  sometimes  admitting  of 
no  delaj",  which  any  general  practitioner  must  undertake,  often  under 
very  unfavourable  surroundings.  It  would  be  most  unfair  to  expect 
that  such  a  man,  when  face  to  face  with  a  gangrenous  hernia,  should 
meet  it  in  the  same  way  as  a  hospital  surgeon,  able  to  command  the 
very  best  surroundings,  abundant  help,  and  himself  experienced  in 
intestinal  surger3\  As  I  have  said  at  p.  40.  when  the  condition  of  the 
patient,  the  experience  of  the  operator,  and  his  surroundings  admit  of 
his  taking  this  step,  resection  of  the  gangrenous  intestine  should  always 
be  performed.  Where  the  above  conditions  are  absent,  the  operator 
must  rest  content   with  enlarging  the  wound,t  drawing  all  the  gan- 

*  The  following  are  some  of  the  most  useful  papers  on  this  subject : — Lockwood 
QMed.-Cklr.  Trans.,  vols.  Ixxiv.  and  Ixxvii.) ;  W.  A.  Lane  (Clin.  Soc.  Trans.,  vol  .xxiv. 
p.  102)  ;  McCosh — three  cases  treated  successfully  by  circular  enterorraphy  (Ann.  of 
Surrj.,  vol.  i.  1894,  P-  647);  Eansohofl:  (ihid.,  vol.  i.  1892)  ;  Mickulicz  {Bed.  Klin.  Woch., 
Nov.  10,  1892)  ;  Eiedel  (iJcut.  Med.  Woch.,  1883.  No.  45)  ;  Reichel  (^iJrut.  Mrd.  Woch., 
1883,  No.  45);  Zeidler  (Cent.  f.  Chir.,  Jan.  16,  1893,  p.  62)  ;  Caird  (Edin.  Med.  Journ., 
1895,  p.  312  ;  Gibson  (Ann.  of  Surg.,  Oct.  and  Nov.  1900). 

f  In  a  very  few  cases,  where  the  surroundings  are  even  more  unfavourable,  the 
operator  may  have  to  be  content  with  simjjly  opening  the  bowel  and  doing  no  more 
(p.  40). 


EESECTIOX   OF  INTESTINE,  ETC.  263 

grenous  intestine  well  outside  the  peritonaeal  sac,  opening  and  draining 
it  thoroughh'  by  one  of  the  means  given  at  p.  178.  This  will  avoid  the 
terrible  risks  of  a  continuance  of  paralysis  of  the  bowel,  stercoraceous 
vomiting,  exhaustion,  or  toxaemia.  The  loop  must  be  kept  outside  by  a 
sterilised  bougie  or  glass  rod,  as  in  inguinal  colotomy  (p.  104),  aided  by 
a  few  sutures.  Any  gangrenous  omentum  must  be  removed,  and  the 
sac  cleansed  as  far  as  possible. 

Operation. — The  intestine  being  found  to  be  gangrenous,  the  extent 
of  this  must  be  first  made  out.  It  is  possible  that  in  a  few  cases  the 
mischief  may  be  so  circumscribed  as  to  involve  only  part  of  the  circum- 
ference of  the  bowel.  Here  the  resection  of  a  very  small  portion  of 
bowel  is  required  ;  while  in  some  it  may  prove  sufficient  merely  to  invert 
and  suture  the  margin  of  the  aperture,  and  it  is  possible  to  accomplish 
this  through  the  original  wound.  Successful  cases  of  partial  resection 
are  recorded  by  Sachs  (Beut.  Zeit.  f.  Chir.,  Bd.  xxxii.  S.  93) ;  Barette 
(These  cle  Paris,  1 883,  "  De  ITntervention  Chii-urgicale  dans  les  Hernies  ") ; 
Lindner  (Berl.  Klin.  Wocli.,  1891.  p.  277).  One  or  two  cases  have  also 
been  recorded  in  America,  but  such  circumscribed  mischief  is  very 
rarely  met  with,  and,  where  such  limited  resection  is  practised,  care 
must  be  taken  to  place  the  sutures  in  healthy  tissues.  Five  cases  of 
partial  gangrene  of  the  intestine  treated  by  inversion  of  the  gangrenous 
or  ruptured  portion  are  very  briefly  given  in  an  instructive  but  ven,' 
short  paper  by  Mr.  Caird  (Edin.  Med.  Journ.,  1895,  P-  312) : 

All  five  were  cases  of  hernia.  There  was  a  "  perforation  "  of  the  intestine  in  one, 
and  a  "  rupture  "  in  two.  Of  the  five  cases,  three  recovered.  Of  the  two  which  died, 
one  was  an  infant  aged  18  months.  The  necropsy  showed  firm  union  of  the  intestine 
without  peritonitis.  "  The  intestine  was  beset  with  typhoid  ulcers  of  ten  or  fourteen 
days'  duration." 

The  following  is  Mr.  Cairds  advice  as  to  the  treatment  of  gangrenous 
intestine  by  inversion,  and  the  cases  suitable  to  this  method  :  "  If  we 
meet  with  the  typical  elliptical  necrosis  of  the  bowel  which  runs  longi- 
tudinally opposite  the  mesenteric  attachment,  we  may,  with  Lembert's 
sutures,  stitch  the  sound  tissues  over  the  unhealthy,  thus  inverting  the 
gangrenous  area  into  the  lumen.  This  practice,  which  obviates  the 
necessity  of  cutting  any  part  of  the  bowel  away,  and  requires  no  special 
dexterity,  is  in  all  probability  not  applicable  with  safety  where  more 
than  one-third  of  the  circumference  is  destroyed.     The  fear  of  stricture 

ensuing  rather  determines  us  to  resect  in  such  cases The  method 

of  inversion,  although  easy,  cannot  be  modified  to  meet  the  exigencies 
of  every  case.  It  does  not  lend  itself  to  those  instances  in  which  the 
gut  is  almost  completely  divided  by  the  tight  grasp  of  a  narrow  femoral 
ring.  The  vitality  of  the  proximal  end  has  then  been  too  severely 
tried  to  admit  of  such  an  experiment.  We  should  require  to  invaginate 
a  few  inches  of  the  damaged  gut  before  we  came  upon  healthy  tissue  to 
suture ;  and  since  it  is  impracticable  to  reproduce  the  successful  natural 
cure  occasionally  seen  in  cases  of  intussusception,  we  are  driven  to 
resect."  If  inversion  be  made  use  of,  the  greatest  care  must  be  taken, 
as  in  partial  or  complete  resection,  to  ensure  that  the  sutiu-es  lie  in 
healthy  tissues. 

Far  commoner  conditions  are  :  (ij  AVhere  a  whole  loop  or  knuckle  is 
gangrenous ;  (2)  while  the  loop  may  appear  fairly  healthy  at  its  neck 
(where  the  pressure  has  been  exerted),  one  or  two  pressure-furrows  or 


264 


OPEKATIONS  OX  THE  ABDOMEX. 


lines  of  ulceration  are  present,  and  the  greatest  care  must  be  taken  in 
drawiho-  this  part  of  the  bowel  down,  or  its  contents  may  escape  into 
the  peritongeal  sac.  (3)  The  gangrene  extends  over  the  convexity  of 
he  loop.  In  these  last  three,  free  resection  passing  through  healthy 
tissues  will  be  required. 

The  first  question  that  arises  when  resection  is  determined  upon  is 
whether  we  should  carr}'  it  out  through  the  original  wound  enlarged, 
or  through  a  second  in  the  linea  alba.  The  answer  to  this  must  depend 
mainlj^  upon  the  variety  of  the  hernia  and  the  means  adopted  for  uniting 
the  resected  ends.     Where  union  by  sutui'ing  is  adopted,  or  a  con- 


FlG.  96. 


Fig   97. 


Two  different  ways  of  dealing  with  the  meseii- 
terj^  in  resection  ot  the  intestine  are  here  shown. 
In  one  the  bowel  is  detached  from  the  mesentery 
a  little  above  their  junction,  all  bleeding  points 
being  carefully  tied,  or  the  two  folds  of  the 
mesentery  united  with  a  fine  continuous  suture. 
The  dotted  outline  of  the  wedge  shows  the  other 
mode  of  dealing  with  the  mesentery.  Drain- 
age-tubes are  used  as  clamps.  (Esmarch  and 
Kowalzig.) 


Here  the  resected  ends  are  shown 
sutured,  and  the  edges  of  the  re- 
dundant fold  of  mesentery  which  is 
i:)resent  where  no  wedge  is  removed 
are  being  united  with  a  continuous 
suture.  Note  that  here  and  in  Fig. 
99  the  union  ot  the  bowel  and  the 
mesentery  is  continuous  across  the 
triangular  interval  at  the  junc- 
tion of  the  two.  (Esmarch  and 
Kowalzig.) 


trivance  of  no  great  size  is  employed,  the  wound,  esi:)ecially  in  a  femoral 
or  umbilical  hernia,  will  simply  need  enlarging  freely.  Where  larger 
foreign  bodies,  such  as  Senn's  plates,  are  emploj^ed,  it  nia}^  be  wiser  to 
make  a  fresh  incision  in  the  linea  alba.*  This  will,  of  course,  run  the 
risk  of  contamination  of  the  periton^eal  sac,  and  call  for  ever}^  precaution 
for  preventing  it.  Any  gangrenous  or  septic  omentum  having  been  tied 
and  removed,  the  sac  and  gangrenous  intestine  are  carefully  cleansed 
with  perchloride  lotion  (l  in  5000),  any  opening  in  the  bowel  being 
temporarily  but  securel}*  closed.  An  incision  having  been  made  below 
the  umbilicus  in  the  linea  alba,  the  damaged  loop  is  drawn  out  of  the 
abdomen  through  this  wound.  Owing  to  the  additional  time  taken  by 
this  fresh  incision,  the  risk  of  contaminating  the  peritongeal  sac,  and  the 


*  Mr.  W,  A.  Lane  made  use  of  this  method  in  two  cases  in  which  he  resected 
gangrenous  hernia,  and  united  the  intestine  by  means  of  Senn's  plates  and  lateral 
anastomosis  (Fig.  no).  One  patient  made  a  good  recovery;  the  other,  whose  condition 
was  very  grave  at  the  time  of  operation,  died  on  tlie  fifth  day,  and  the  necropsy  showed 
a  perforated  gangrenous  patch  on  the  upper  piece  of  the  intestine  (^Clin.  Soc.  Tram., 
vol.  xxiv.  p.  182). 


EESECTIOX  OF  INTESTINE.   ETC. 


265 


A  piece  of  intestine  has  been  resected  without 
removing  anj-  mesentery.     (Mac  Cormac.) 


fact  that  now,  Avlieu  the  resected  ends  can  be  safeh^  united  by  suture 
alone,  or  b}-  a  small  body  such  as  Murphy's  Initton  or  Robson's  bobbin, 
we  can  dispense  with  such  large  bodies  as  Senn's  plates,  it  will  be 
better  to  perform  the  resection  through  the  original  wound,  which  must 
be  prolonged,  if  necessary,  upwards  in  a  femoral  hernia,  dividing 
Poupart's  ligament,  upwards  or  downwards  in  an  umbilical,  and  upwards 
along  the  linea  semilunaris  in  an  inguinal  hernia.  The  damaged  loop 
having  been  drawn  well  out,  the  peritonceal  sac  is  sliut  off  with  gauze, 
and  clamps  applied  as  advised  at  p.  259,  care  being  taken  to  get  well 
above  the  inflamed  parts,  and  so  to  secure  speedy  and  sound  plastic 
union.  The  intestine  to  be  sacrificed  is  now  cut  away,  care  being  taken 
to  remove  too  much  rather  than 

too  little ;  for  we  find,  in  many  ^^^^-^ 

of  the  fatal  cases  reported,  that 
the  cause  of  death  was  attributed 
to  gangrene  spreading  upwards 
above  the  seat  of  suture  ;  on  the 
other  hand,  we  find  that  recovery 
lias  followed  when  large  portions 
of  the  intestine  have  been  re- 
moved. Thus,  Kamdohr  excised 
2  feet;  Rj'dyggier  had  a  case  in 
which  54  centimetres  were  sacri- 
ficed ;  Rushton  Parker  cut  out 
12  inches;  Walter  also  i-emoved 

2  feet  4  inches  ;  and,  lastly,  Koclier  had  a  patient  who  left  the  hospital 
perfectly  well  on  the  eighteenth  day,  after  having  had  about  5^  feet  of 
intestine  removed.  All  these  patients  recovered  (Kendal  Franks,  Lancet, 
vol.  i.  1893,  p.  1387).  The  rule  must  be,  therefore,  to  remove  every  atom 
of  suspicious  boM'el.  and  to  cut  through  and  place  the  sutures  in  health}' 
tissues.*  It  would  seem  from  published  cases  that  the  mesentery 
may  with  equal  success  be  treated  as  in  Fig.  96,  by  excision  of  a  wedge, 
or  as  in  Figs.  97,  99.  In  this  latter  case  the  mesentery  is  divided 
as  close  to  the  bowel  as  possible.  As,  however,  more  time  is  occupied 
by  the  removal  of  a  wedge,  since  many  more  vessels  have  to  be  tied, 
and  as  there  is  no  corresponding  advantage  gained  by  so  doing,  the 
.simpler  plan  of  uniting  the  cut  edges  as  in  Figs.  97  and  99  is  to  be 
preferred. 

The  ends  having  been  resected,  the  intestine  above  emptied,  cleansed, 

*  Lockwood  gives  the  useful  hint  to  cut  through  the  collapsed  distal  end  first,  as  the 
gangrenous  portion  and  the  distended  end  may  then  be  drawn  further  from  the  wound, 
and  used  as  a  spout  to  carry  ofE  the  frecal  accumulation  QJIed.-Chir.  Trans.,  vol.  Ixxiv. 
p.  213).  Caird  (^Edin.  Med.  Jonrti.,  vol.  ii.  1895,  P*  3^4)  advises  thus  on  this  point : 
The  peritouEeum  being  well  shut  off,  "just  beyond  the  distal  end  of  the  gangrenous 
mass  a  couple  of  long-bladed  pressure-forceps  should  be  applied  side  by  side,  and  the 
gut  completely  divided  between  them.  The  mesentery  should  now  be  severed  along  its 
attachment  to  the  portion  of  gut  we  wish  to  remove,  and  this  enables  us  to  hold  the 
free  extremity  over  a  vessel,  when,  on  removing  the  forceps,  the  contents  escape  and 
the  congestion  abates.  Having  thus  relieved  the  congestion  and  emptied  the  gut.  we 
may  now  reapply  the  forceps  on  the  central  healthy  gut,  and  cut  away  the  intervening 
damaged  portion."  Mr.  Caird  considers  that  if  the  pressure-forceps  have  inflicted  any 
permanent  damage  on  the  cut  margin  of  the  gut  that  edge  becomes  inverted,  thanks  to 
the  Lembert's  sutures  (vide  infra). 


266 


OPERATIO^sS  OX  THE  ABDOMEN. 


and  the  clamp  above  reapplied,  the  union  of  the  resected  ends  is  carried 
out  by  the  particular  method  that  has  been  decided  upon  (ride  p.  227, 
et  seq.).  The  clamps  having  been  removed,  the  bowel,  cleansed  and 
dusted  with  iodoform,  is  returned;  the  upj^er  part  of  the  wound  is  next 
closed  with  deep  sutures,  the  lowest  of  which  should  obliterate  the  neck 
of  the  sac.  Poupart's  ligament,  if  divided,  must  be  united  by  buried 
sutures.  As  the  sac  will  almost  certainly  have  been  septic,  drainage 
should  be  employed. 

The  question  of  the  advisability  of  attempting  a  radical   cure  now 

arises.    Very  often  this  will  be  forbidden  by  the  general  condition  of  the 

patient.     Whenever  there  is  any  risk  of  septic  infection,  or  any  doubt 

as  to  the  efficiency  of  the  suture,  the  wound  must  be  kept  open.  Mickulicz 

I  understand  him  rightly  (loc.  swpra  cit.),  leaves  these  cases  open. 

If  any  extravasation  have  taken  place  into  the  peritongeal  sac,  this 

must  be  cleansed,  and  drainage  employed  as  advised  at  pp.  207,  217. 

It  may  be  convenient  to  briefly  recapitulate  here  the  chief  courses 

open  in  the  treatment  of  gangren- 
ous hernia,  (i)  Leaving  things 
alone  (p.  40) ;  a  course  only  to 
l^e  adopted  when  the  condition  of 
the  patient  and  the  surroundings 
of  the  surgeon  do  not  admit  of 
more  being  done.  (2)  Primary 
resection  either  of  a  portion  of 
a  coil,  as  in  a  gunshot  womid,  or 
more  usually  of  the  whole  loop. 

(3)  Intermediate  resection  (Riedel, 
Dent.  Med.  Woch.,  1883,  No.  45). 
Resection  is  performed,  an  artifi- 
cial anus  established,  and  after 
twenty-four  or  forty-eight  hours 
the  edges  of  the  intestine  are 
vivified    and    united   by    suture. 

(4)  Enterostomy,  or  the  making 
of  an  artificial  anus  and  the  clo- 
sure of  this  at  a  subsequent  date. 

In  cases  where  the  collapse  of  a  patient  demands  prompt  termination 
of  the  operation,  the  surgeon  should  insert  two  Paul's  tubes  in  the 
ends  of  the  intestine,  keeping  these  well  outside  (Fig.  91).  The 
spur  and  the  artificial  anus  must  be  closed  later  on  (p.  258).  (5)  If  an 
unfavourable  change  take  place  in  the  patient's  condition,  before  the 
surgeon  has  time  to  complete  the  suturing  to  his  satisfaction,  he  may 
adopt  Bouilly's  mixed  method  (Fev.  de  Chir.,  1883).  The  ends  of  the 
intestine  are  sutured  together  by  Lembert's  method,  with  the  excep- 
tion of  a  small  portion  on  the  convex  border,  opposite  its  mesenteric 
attachment,  where  an  opening  is  left.  The  edges  of  this  are  sutured  to 
the  abdominal  wound,  a  fsecal  fistula  being  thus  formed,  which  Bouilly 
maintains  will  shortly  close.  In  any  case  in  \\'hicli  I  was  not  satisfied 
as  to  the  completeness  and  efficacy  of  the  sutures,  I  should  prefer  to 
place  the  sutured  bowel  just  within  the  abdomen,  and  pack  it  round 
with  iodoform  gauze  to  shut  off  the  peritonasal  sac  until  union  is 
assured.     In  twenty-four  or  thirty-six  hours  it  will  be  safe  to  remove 


The  intestine  lias  been  sutured,  and  tlie 
mesentery  appears  as  a  redundant  fold  whose 
edges  have  been  united  by  a  continuous  suture. 
(Mac  Cormac.)  Sir  William  considered  that 
this  method  of  dealing  with  the  mesentery 
would  obviate  to  a  large  extent  the  risk  of 
gangrene  of  the  bowel. 


KESECTION  OF  INTESTINE,   ETC. 


267 


the  gauze  and  to  close  the  wound  by  means  of  provisional  sutures 
inserted  at  the  time  of  the  operation.  Or  the  following  precaution  may 
be  adopted. 

Omental  Grafting  (Figs.  100,  10 1,  and  102). — This  is  one  of  those 
details  in  intestinal  surgery  which  we  owe  to  Senn.  To  strengthen  a 
weak  spot  or  line  of  union  a  strip  of  omentum  is  torn,  not  exit,  from  the 

Fig.  100. 


Ileo-ileostomy,  with  Senn's  plates,  completed.  An  omental  graft  has  been  placed 
over  the  line  of  union.  From  a  specimen  removed  from  a  dog  some  time  after 
recovery.     (Jessett.) 

free  end  of  the  omentum,  laid  over  the  spot  which  it  is  intended  to 
strengthen,  and  secured  with  a  few  sutures.  The  contiguous  surfaces 
may  first  be  lightly  scarified,  short  of  causing  bleeding.  Another 
method,  that  of  leaving  the  graft  attached  by  one  end,  should  not  be 
adopted,  as  this  may,  later,  bring  about  ill  results  in  the  form  of 
intestinal  obstruction. 


Fig.  ioi. 


Ileo-colostomj'.  The  line  of  implantation  of  the  small  into  the  large  intestine  has 
been  covered  with  an  omental  graft.  From  a  specimen  removed  from  a  dog  some 
time  after  recoverj'.     (Jessett.) 

In  the  after-treatment  of  resection  cases  collapse  must  be  vigorously 
combated,  feeding  b}'  the  bowel  trusted  to  for  thirty-six  or  forty-eight 
hours,  and  as  little  morphine  or  opium  given  as  possible,  for  fear  of  ••  con- 
ducing to  further,  and  perhaps  fatal,  intestinal  paralysis"  (Lockwood). 
Flatus  will  probably  be  passed  in  forty-eight  hours,  and  the  bowels  act 
between  the  fourth  and  sixth  days. 

Treatment  of  Intestine  which  is  Dangerous  though  not  actually 


268 


OPERATIONS  OX  THE  ABDOMEX, 


Gangrenous. — Before  leaving  the  subject  of  gangrenous  intestine  in 
hernia,  and  its  treatment,  there  is  one  remaining  allied  class  of  hernia 
often  ver}^  fatal,  for  which  modern  surgerymay  do  much,  viz.,  that  in  which 


Fig.   I02 


the  condition  of  the  bowel  is  such  that,  though 


gangrene  is  not  yet  present,  this  may  set  in 
if  the  bowel  be  returned  into  the  abdomen. 
In  Ransohoff 's  words  (Joe.  supra  cit. ;  Ann.  of 
Snr(j.,  vol.  ii.  1 892,  p.  349),  "Such  a  knuckle  is 
a  menace.  Bowel  that  is  not  at  all  doubtful  in 
appearance  will  at  times  repay  the  trust  placed 
in  it  b}"  a  perforation.  Among  ninety-six  deaths 
after  herniotomy  it  was,  in  twentj^-six  cases,  the 
result  of  returning  intestine  which  subsequently 
perforated.  To  return  doubtful  intestine  is  neces- 
sarily jeopardising  life.  To  treat  such  intestine 
as  radically  as  bowel  already  gangrenous  is  an 
extreme  measure  not  to  be  advocated.  For- 
tunately the  intestine  can  be  retained  in  the 
wound  for  a  number  of  days  in  gauze  packing 
or  by  sutures.  When  its  viability  has  been  esta- 
blished it  is  an  easy  matter  to  return  it  into 
the  abdomen."  Graefe  has  reported  (Dent.  Zeit. 
f.  Chir.,  Bd.  xxxiv.  S.  82)  a  successful  case  in 
which  the  intestine  was  so  retained  for  five  daj'S 
before  it  was  replaced. 
While  I  entirely  agree  with  Dr.  Ransohoff  in  the  principle  of  the 
above,  I  think  he  represents  the  returning  of  such  intestine  as  unduly 
easy.  Even  after  twent3'-four  or  thirty-six  hours,  the  earliest  date  at 
which  it  will  be  safe  to  return  it,  the  intestine  will  be  found  adherent  to 
the  gauze  and  to  bleed  easily. 


All  omental  graft  seciu-ed 
in  ijlace  over  the  line  of  an 
enterorraiihj-.  I,  Intestine. 
M,  Mesentery.  O,  Graft. 
S,  Snture  fixing  graft. 
(Walsham.) 


INTESTINAL     ANASTOMOSIS,        SHORT-CIRCUITING. 
LATERAL     ANASTOMOSIS. 

The  first  two  of  the  above-given  terms  have  been  often  needlessly 
used  for  the  same  thing — viz.,  the  establishment  of  a  permanent  fistulous 
opening  between  the  bowel  above  and  the  bowel  below  some  point  of 
obstruction,  usually  a  growth  which  cannot  be  removed. 

By  Lateral  Anastomosis  is  meant  the  making  of  a  fistulous  opening 
between  t^^•o  parts  of  resected  intestines,  the  two  ends  being  first  securely 
closed. 

However  end-to-end  junction  of  resected  intestine  may  ultimatel)^  be 
performed,  it  is  certain  that  the  above  operations  have  a  great  future 
before  them.  The  principle  of  them  all,  and  the  making  them  of 
pi'actical  utility,  \\e  owe  to  the  labours  and  experiments  of  Prof.  Senn. 

Indications. — Intestinal  anastomosis  or  short-circuiting  are  to  replace 
resection  where  the  general  and  local  conditions  forbid  the  severer  step 
in  such  cases  as — (a)  Growth  ;  for  cases  suitable  for  resection  seep.  256. 
(/S)  Contraction,  cicatricial  and  not  malignant  in  character.  (7)  Matting 
of  intestines  b}'  old  mischief,  perhaps  dating  to  tubercular  peritonitis,  or 
inflammation  about  a  caseous  mesenteric  gland,  (h)  An  intussusception 
which  is  irreducible  but  not  gangrenous. 


INTESTINAL  ANASTOMOSIS.   ETC. 


269 


Advantages. — Prof.  Senn  claims  the  following,  and  with  regard  to 
the  principle  of  intestinal  anastomosis  all  will  agree  with  him.  As 
regards  the  details  as  to  which  method  is  the  best,  time  alone  will  show, 
(i)  That  the  operation  can  be  rapidly  performed  with  a  great  saving  of 
time.  (2)  That  the  junction  of  the  intestinal  surfaces  around  the 
anastomosis  is  a  safe  one.  (3)  That  the  operation  is  independent  of  any 
difference  in  the  size  of  the  bowel  above  and  below  the  obstruction. 
(4)  That  the  principle  is  of  very  wide  application.  The  objections  are 
given  at  p.  249. 

Operation. 

I.  Lateral  Anastomosis  with  Murphy's  Button  (Fig.  103). 
— The  technique  here  differs  but  little  from  that  already  given  for  end- 
to-end  junction  by  this  method.  Similar  spots  in  the  ileum  and  cascum 
having  been  chosen,  a  needle  threaded  with  about  a  foot  of  silk  is  inserted 
in  the  long  axis  of  the  bowel  as  at  Fig.  103  ;  a  stitch  is  taken  through 
the  entire  wall  of  the  bowel,  one-third  the  length  of  the  incision  to  be 
made ;  the  needle  is  again  inserted,  one-third  the  length  of  the  incision 
from  its  outlet,  in  a  line  with  the  first,  and  embracing  the  same  amount 


Fig.  103. 


This  shows  the  method  of  passing  the  puckering  thread  when  Murphy's  button 
is  used  in  lateral  intestinal  anastomosis,  gastro-enterostomy,  i*cc. 

of  tissue.  A  loop,  three  inches  long,  is  held  here,  and  the  needle  is 
inserted  in  a  similar  manner,  making  two  stitches  parallel  to  the  first 
in  the  reverse  direction,  and  one-fourth  of  an  inch  from  it,  coming  out 
at  a  point  near  the  original  insertion  of  the  needle.^  This  fornis  the 
running  thread  (Fig.  103)  which,  when  tightened,  draws  the  incised 
edge  of  the  bowel  within  the  cup  of  the  button.  A  similar  runnino- 
thread  is  inserted  in  like  fashion  in  the  colon.  Incisions  two-thirds  the 
length  of  the  diameter  of  the  button  to  be  used  are  then  made  between 
the  two  running  threads  (Fig.  103),  care  being  taken  not  to  cut  these, 
the  female  half  of  the  button  slipped  into  the  ileum  and  the  male  into 
the  colon,  the  ruiming  thread  drawn  tight  and  tied  firmlv  round  the 
central  cylinders.  While  this  is  done,  an  assistant  holds  each  half  in 
place,  and  care  is  taken  that  the  intestine  is  held  evenly  all  round  the 
cylinder  in  the  grip  of  the  ligature.  The  two  halves  of  the  button,  next 
held  in  the  fingers,  are  firmly  pressed  together  until  the  serous  surfaces 
are  in  accurate  contact  all  round  and  at  every  point. 
II.  Lateral  Anastomosis  by  Sutures  alone  (Figs.  104-108). 

— Son)e  of  the  best  American  surgeons  are  abandoning  artificial  aids 
in  anastomosis  and  preferring  to  trust  to  sutures  alone,  just  as  in 
end-to-end  union  they  have  returned  to  circular  enterorraphy.  The 
method  of  Abbe,  which  has  given  good    results,  is  as  follows  :    After 


270 


OPERATIONS  OX  THE  ABDOMEX, 


resection  of  the  intestine  and  closure  of  the  two  ends,  the  two  segments 
of  intestine  are  laid  parallel  with  each  other,  and  two  rows  of  continuous 
Fig.  104.  Fig.  105. 


Abbe's  method  of  anastomosis  by  sutures 
ouly.  To  show  the  suturing  of  the  intes- 
tine before  the  incision  is  made.  {American 
Text-book  of  Surgery.) 

Fig.   106. 


To  show  the  four-inch  openings  and  the 
sewing  of  the  edges.  {American  Text-book 
of  Surgery.) 

Fig.   107. 


Method  of  lateral  anastomosis  by  Halsted's  simple  suturing.    The  sutures  are  of  the 
square  kind.    Fig.  106,  first  stage;  Fig.  107,  second  stage.    (.Jessett,  from  Halsted.) 

Fig. 


Halsted's  operation,  third  and  fourth  stages.     (Jessett,  from  Halsted.) 

Lembert's  sutures  are  applied  a  quarter  of  an  inch  apart  and  an  inch 
longer  than  the  incision  which  it  is  proposed  to  make  (Fig.  1 04).  Each 
piece  of  silk  (twenty-four  inches  long)  is  left  at  the  end  of  its  row,  being 
still  threaded.      The  bowel  is  then  opened  for  four  inches,  a  quarter 


INTESTINAL  ANASTOMOSIS,   ETC. 


271 


Fir..  109. 


of  an  inch  from  the  sutures,  both  rows  being  to  one  side  of  the  cut. 
Any  vessels  that  bleed  are  treated  by  forci-pressure.  The  opposite 
segment  of  bowel  is  then  opened  in  the  same  way.  The  two  adjacent 
cut  edges  are  now  united  b}'  a  suture  which  traverses  both  the  mucous 
and  serous  wall  (Fig.  105),  and  so  secures  any  bleeding  points,  the 
forceps  being  taken  off  as  they  are  reached.  The  two  free  cut  edges 
are  secured  with  a  similar  "•  whipping " 
stitch,  after  which  the  serous  surfaces  on 
the  opposite  side  of  the  opening  are  ap- 
proximated and  secured  by  continuous 
Lembert's  sutures,  the  first  threads  secur- 
ing this  purpose.  It  is  claimed  that  this 
method  requires  little,  if  an}-,  longer  time 
than  that  with  plates  or  rings  of  any  kind, 
and  that  it  is  free  from  many  of  their 
disadvantages,  viz.,  the  need  of  special 
apparatus,  foreign  bodies  which  have  to 
come  awa}',  contraction  of  the  opening, 
which  is  here  so  very  free,  and  the  col- 
lapse of  the  mucous  membrane  through 
the  opening. 

Dr.  Halsted  has  described  another 
method  of  intestinal  anastomosis  by 
suture  onl}'  (^Bulletins  Johns  HopMiis 
Hospital,  vol.  ii.  No.  10).  He  prefers 
quilt  or  square  sutures  (Figs.  106  to  108) 
because  one  row  is  sufficient,  and  they 
tear  out  less  easily  and  constrict  the 
tissues  less  than  do  the  Lembert's  sutures, 
of  this  method.  The  two  selected  portions  of  intestine  having  been 
placed  in  contact  along  their  mesenteric  borders,  six  square  sutures  are 
put  in  a  straight  row,  tied,  and  cut  short.  At  each  end  of  this,  the 
l)Osterior  row  of  sutures,  and  nearer  the  free  border,  two  lateral  square 
sutures,  are  applied  (Fig.  107),  tied,  and  cut  short.  Eight  or  nine  square 
sutures  are  now  applied  so  as  to  draw  together  the  free  borders.  These 
sutures  are  not,  however,  tied,  but  drawn  aside  (Fig.  108).  so  as  to  make 
I'oom  for  the  scissors  with  which  the  two  segments  of  intestine  are 
opened.     Finally,  the  sutures  of  the  anterior  row  are  tied  and  cut  short. 

III.  With  Senn's  Plates.* — These  were  substituted  for  sutures 
by  their  ingenious  author  with  the  object  of  (a)  saving  time,  (b)  doing 
away  with  the  evils  of  numerous  sutures,  (c)  of  securing  a  wider  ap- 
proximation of  serous  surfaces,  and  a  more  complete  rest  for  the  parts 
to  be  united.  The  decalcified  bone  plates,  each  with  the  four  sutures, 
two  above  and  below  at  the  ends,  and  two  at  the  sides,  are  well  known 
(Fig.  109). 

If  the  plates  are  not  threaded  this  can  be  quickh'  done  by  passing- 
two  round  needles,  carrying  about  twenty-four  inches  of  silk,  from 
l)efore  backwards  through  one  end  jierforation,  and  then  from  behind 
forwards  through  one  lateral  perforation.  The  needles  are  cut  away 
and  the  four  ends  knotted  (Fig.  109). 

*  Although  to  some  this  method  may  appear  out  of  date,  it  is  retained  here  in 
deference  to  the  brilliant  ingenuity  of  its  inventor. 


A  Seuu's  decalcified  bone-plate 
ready  for  use .  When  the  first  th  reads 
have  been  passed  they  should  be 
secured  to  the  back  of  the  plate 
and  to  each  other  by  another  thread 
passing  between  each  as  in  the 
figure.  Tlie  plates  should  be  kept 
in  a  solution  of  equal  parts  of  alco- 
hol, glycerine,  and  water,  being 
placed  in  i  — 40  carbolic  acid  lotion 
before  use.  They  are  on  no  account 
to  be  inserted  dry,  owiug  to  the  cer- 
tainty of  their  swelling  and  causing 
tension,  sloughing,  &c.  (Walsham.) 

The  following  are  the  steps 


272 


OPERATIONS   OX   THE  ABDOMEN. 


As  an  instance  of  this  operation  we  will  take  ileo-colostomy  or  anas- 
tomosis of  the  ileum  and  ascending  colon,  when  a  carcinoma  of  the 
csecum — a  common  instance  of  malignant  disease  of  the  intestine — is 
found  not  to  admit  of  removal.  An  incision  having  been  made  over 
the  mass,  horizontally  or  vertically,  or  in  the  right  linea  semilunaris,  as 
advised  at  j).  259,  a  suitable  piece  of  the  ileum  and  the  ascending  colon* 

Fig.  1 10. 


Intestinal  anastomosis — ileo-colostomy — with  Senu's  plates.  These  have  not  yet 
been  approximated.  The  csecum  here  has  not  been  resected.  Cf.  with  Fig.  113. 
a,  a,  Lateral  transfixion  or  fixation  sutures  passed  through  the  intestine,  aa,  aa, 
]5nd  or  apposition  sutures  hanging  out  of  the  wound,  b,  h.  Posterior  or  row  of 
Lembert's  sutures.     (.Jessett,  from  Senn.) 

are,  if  possible,  brought  into  the  woimd.  If  this  cannot  be  effected  the 
pieces  of  bowel  chosen  and  the  area  of  operation  must  l)e  carefully  packed 
off  with  iodoform  gauze  or  sponges. t     The  parts  which  are  to  be  joined 


*  In  Sir  F.  Treves's  words  (^Oper.  Sunj..  vol.  ii.  p.  340),  these  two  parts  of  bowel "  should 
not  be  so  far  distant  from  one  another  as  to  exclude  a  large  tract  of  intestine  after  the 
operation  is  complete,  nor  so  near  as  to  expose  the  actual  area  of  disease,  or  to  render 
the  manipulation  of  the  parts  difficult.  It  is  probable  that  the  upper  coil  will  be 
distended  and  hypertrophied,  and  the  lower  empty  and  wasted." 

t  I  prefer  both  in  a  case  of  this  kind :  fiat  sponges  (held  by  Spencer  Wells's  forceps) 
pushed  well  into  the  abdomen  to  keep  the  small  intestine,  (Sec,  back;  and  over  these, 
tampons  of  iodoform  gauze  lining  the  edges  of  the  wound. 


INTESTINAL  ANASTOMOSIS,  ETC. 


273 


by  anastomosis  having  been  brought  outside,  they  are  laid  on  aseptic 
gauze,  gently  emptied  with  the  fingers,  and  kept  so  with  clamps  of 
some  kind  (p.  259).  If  the  upper  end  be  much  distended  the  opening 
for  the  plate  is  made  at  once.  An  incision  about  an  inch  and  a  half 
long*  is  made  in  the  long  axis  of  the  ileum  on  its  free  border,  and  the 
contents  allowed  to  escape  where  they  can  do  no  harm.  Any  free 
bleeding  from  the  incision  will  yield  to  forci-pressure  without  ligature. 
If  there  be  plenty  of  time  it  will  be  well,  as  advised  by  Mr.  Jessett,  to 
run     a     continuous     suture 

around  each  opening  (Fig.  Fi«.  m. 

105)  ;  this  will  arrest  any 
bleeding,  and  prevent  the 
closure  of  the  wound  and 
prolapse  of  the  mucous 
membrane.  The  lumen  of 
the  opened  intestine,  as  far 
as  it  can  be  reached,  having 
been  cleansed  with  pledgets 
of  aseptic  wool,  a  bone  plate 
(Fig.  109),  threaded,  is  in- 
serted edgeways,  and  when 
it  is  completely  within  the 
lumen  of  the  bowel,  traction 
is  so  made  on  the  sutures  as 
to  bring  the  plate  with  its 
threaded  surface  upwards 
in  the  wound,  and  with  its 
central  opening  accurately 
placed  with  reference  to  the 
opening  in  the  intestine 
(Fig.   no). 

The  plate  is  then  fixed  in 
this  position  by  transfixing 
the  wall  of  the  bowel  near 
the  edges  of  the  opening, 
and  at  spots  equidistant 
from  its  angles  with  the 
lateral  sutures  (a,  o.  Fig. 
1 10).  The  end  sutures  hang 
out  of  the  upper  and  lower 
angles  of  the  wound  (aa,  aa, 
Fig.  no).  A  longitudinal 
incision  is  next  made  in  the  colon,  opposite  to  the  meso-colon,  well 
above  the  disease,  and  a  bone  plate  introduced  here  with  precautions 
similar  to  those  already  given. 

The  peritongeum  covering  each  plate  is  now  lightly  scarified  with 
numerous  cross  lines  made  by  a  needle,  but  not  deep  enough  to  cause 
bleeding,  and  the  serous  coats  where  these  are  in  contact  along  the 


Intestinal  anastomosis — ileo-colostomy — withSenn's 
plates.  Tljese  are  now  approximated  and  the  anterior 
row  of  sutures  is  being  applied.  The  cscum  here  has 
not  been  resected.  Cf.  with  Fig.  113.  (Jessett,  after 
Senn.) 


*  If  the  opening  be  too  small,  force  will  have  to  be  employed  in  inserting  the  plate, 
and  bruising  will  follow  ;  if  too  large,  the  plates  may  escape  or  ride  loosely  after  the 
sutures  have  been  tied. 

VOL,  II.  18 


74 


OPERATIONS  OX  THE  ABDOMEN. 


Fig.  112. 


posterior  margins  of  the  plates  are  united  with  a  few  superficial  sutures 
(Fig.    no). 

The  plates  being  how  held  in  accurate  apposition  by  an  assistant, 
the  threads  M'hich  have  previously  been  identified  are  tied  in  the  follow- 
ing order :  iirst,  the  inner  lateral  sutures  (these  are  shown  in  process  of 
tying,  Fig.  Iio);  next  the  pair  of  end  threads  which  are  farthest  from 
the  operator  are  tied,  and  then  the  opposite  pair.  In  tjdng  these,  the 
threads  must  be  drawn  do^^'n  between  the  plates.  Finally  the  only, 
remaining  or  the  outer  lateral  threads  are  tied.  In  tying  each  of  the 
four  pairs,  sufficient  force  only  must  be  used  to  bring  and  keep  the 
plates  together,  and  to  ensure  firm  knots.  All  that  now  remains  is  to 
reinforce  the  threads  which  have  been  tied  by  running  together  the 
serous  surfaces  along  the  anterior  margins  of  the  plates  by  a  few  points 
of  sutures,  or  a  continuous  one  (Fig.  in). 

The  parts  are  now  carefully  cleansed,  the  clamps  taken  off,  the  flat 
sponges  and  gauze  tampons  removed,  and  the  peritonasal  sac  cleansed 
of  any  blood  clot,  &c.     A  little  iodoform  is  now  rubbed  along  the  lines 

of  sutures  in  the  intestines 
operated  on,  and  the  parts 
returned.  The  w^ound  is 
then  closed  in  the  usual 
wa}^ 

Anastomosis  with  Senn's 
plates  after  excision  of  the 
csecum. — Intestinal  anasto- 
mosis, e.g.,  ileo-colostomy  in 
cases  where  removal  of  the 
ileo-caecal  coil  was  impossi- 
ble, having  been  described, 
we  shall  next  imagine  a 
case  where  it  has  been  pos- 
sible to  remove  the  bowel, 
but  the  surgeon  prefers  to 
unite  the  ends  by  lateral 
anastomosis  instead  of  end- 
to-end  union.  The  account 
is  Prof.  Senn's  {.Tourn.  Amer.  Med.  Assoc,  3\\ne  14,  1890):  "After  all 
haemorrhage  had  been  carefully  arrested  both  resected  ends  were  closed 
by  invagination  and  a  few  stitches  of  the  continuous  suture  (a,  Fig. 
1 1 3).  The  first  stitch  was  made  to  transfix  the  mesentery  at  the  point 
where  it  was  invaginated  into  the  bowel.  Medium-sized  perforated 
decalcified  bone  plates  were  used  in  making  the  ileo-colostomy  by 
lateral  approximation.  An  incision  about  two  inches  in  length  was  made 
in  the  closed  ends  of  both  intestines  at  a  point  opposite  the  mesenteric 
attachment,  and  into  each  opening  a  bone  plate  was  inserted,  and 
the  lateral  sutures,  armed  with  a  needle,  were  passed  about  an  eighth 
of  an  inch  from  the  margin  of  the  wound  at  a  j)oint  half-way  bet^^■een 
the  angles  of  the  intestinal  wound.  The  margins  of  the  bowel  corre- 
sponding to  the  parts  covering  the  plates  were  freely  scarified  with  an 
ordinary  sewing  needle.  The  visceral  wounds  were  now  broiight  vis-d- 
vis  in  such  a  manner  that  both  closed  ends  were  directed  downwards, 
bringing  in  this  manner  the  free  surface  of  the  colon  and  ileum  together. 


Intestinal  anastomosis  by  Senn's  plates  after  com- 
plete resection  of  a  part  of  the  small  intestine.  The 
ends  have  been  closed  by  a  continuous  Lembert's 
suture.     (Walsham.) 


INTESTINAL  ANASTOMOSIS,  ETC. 


-/  :> 


Before  any  of  the  plate-sutures  were  tied,  a  number  of  Lembert  sutm-es 
were  applied  posteriorly,  sufficiently  far  back  so  that  after  the  approxi- 
mation they  should  be  just  beyond  the  borders  of  the  plates,  thus 
affording  sufficient  security  in  maintaining  co-aptation.  The  posterior 
pair  of  transfixion  sutures*  were  now  tied,  after  which  both  pairs  of  the 
sutures  not  armed  with  needles  were  tied.  During  the  tying  of  these 
sutures,  it  is  of  the  greatest  importance  that  an  assistant  should  ke^p 
the  plates  accurately  and  closely  pressed  together.  The  last  sutures  to 
be  tied  were  the  second  pair  of  fixation  sutures  :  and  as  this  was  being 
done,  the  bowel  on  each 
side  was  carefully  jiushed  in 
between  the  plates  with  a 
probe.  The  sutures  were 
tied  in  a  scjuare  knot,  and 
only  with  siifficient  firmness 
to  bring  the  parts  in  apposi- 
tion, as  any  undue  pressure 
would  have  been  detrimen- 
tal, and  might  have  resulted 
in  gangrene  of  the  tissues 
included  between  the  plates. 
The  sutures  were  cut  short, 
and  the  ends  brought  as 
near  the  opening  as  pos- 
sible, by  pushing  them 
in  this  direction  with  a 
probe.  After  all  the  ap- 
proximation sutures  were 
tied,  it  only  remained  to 
apply  in  the  upper  side 
a  few  Lembert  sutures  or  a 
continuous  one  (b,  Fig.  1 13J 
in  the  same  manner  as  was 
done  on  the  opposite  side 
before  any  of  the  approxi- 
mation sutures  were  tied." 
Mr.  Littlewood,  of  Leeds, 
has  suggested  {Lancet,  vol.  i. 
1892,  p.  866)  a  modifica- 
tion of  Senn's  plates,  with 
the  object  of  (i  J  doing  away 
with  the  sutures,  some  of 
which  perforate  the  whole 
thickness  of  the  bowel,  and 
thus  may  introduce  sepsis ; 
quickly ;    (3)  of  ensitring  a 


lutestiual  anastomosis — ileo-colostomy  with  Senn's 
plates.  The  caecum  here  has  been  resected.  Cf.  with 
Figs  no  and  in.  a,  Closed  ends  of  ileum  and  colon. 
b,  A  continuous  suture  uniting  the  serous  surfaces 
over  the  anterior  margins  of  the  plates.  (Jessett, 
after  Senn.) 


(2)  of  performing  the  operation  more 
good  opening  between  the  two  \-iscera. 
The  suggested  modification  is  that  by  means  of  a  decalcified  bone  tube 
fixed  in  its  opening,  one  plate  fits  accurately  into  the  aperture  of  the 
other.  By  this  means  it  is  thought  that  the  two  plates  would  be  held 
together,  while  the  two  visceral  walls  between  them  would  be  brought 
evenlv  in  contact  with  each  other. 


The  two  seen  tied  between  the  two  plates  in  Fig.  no. 


276 


OPERATIONS  ON  THE  ABDOMEN. 


CLOSUKE    OF    PJECAL    FISTULA    OR    ARTIFICIAL    ANUS. 


Fig.  114. 


Fig.  1 14  shows,  diagrammaticallv,  some  of  the  chief  points  of  difference 
between  a  faecal  fistnla  and  an  artificial  anus.  Before  operating,  certain 
points  of  much  practical  importance  should  be  considered,  and  first  how 
far  any  spur  or  septum  is  developed.  The  more  marked  this  is,  the  less 
is  the  chance  of  closing  the  opening  by  any  slight  plastic  operation 
such  as  paring  and  suturing  the  edges  of  the  opening.     The  spur  being 

left  behind,  the  faeces  will  make 
their  wa}'  through  the  sutures^ 
and  the  longer  this  condition 
is  allowed  to  remain,  the  more, 
of  necessity,  will  the  lower 
segment  of  intestine  atrophy, 
and  the  more  marked  will  be 
the  difference  between  the  twO' 
parts  of  the  bowel.  Other 
important  points  are  the  nutri- 
tion of  the  patient  and  the 
condition  of  the  area  surround- 
mg  the  wound.  The  higher 
the  fistula  is  situated  in  the 
small  intestine  the  more  will 
the  nutrition  have  suffered,, 
and  the  more  profuse  and  liquid 
is  the  discharge  the  wider  and 
the  more  infiltrated  will  be  the 
eczematous  area  around. 

Previous  Treatment. — We 
will  suppose  that  the  pressure 
of  a  truss,  the  cautery,  the 
destruction  of  the  spur,*  and 
the  use  of  india-rubber  tubing, 
have  each  been  tried  in  suit- 
able cases. 

Sir  W.  M.  Banks  (Clin. 
Notes,  p.  94)  describes  the  fol- 
lowing simple  and  ingenious 
method.  Where  the  septum  or 
spur  is  not  well  developed,  it 
ma}^  be  expected  to  succeed 
In  an  artificial  anus  in  the  groin,  after  a  femoral  hernia,  he  introduced 
a  thick  piece  of  india-rubber  tubing,  pushing  one  end  up  the  ascending 
and  the  other  down  the  descending  bowel.  It  was  secured  by  silk 
brought  out  of  the  opening.  It  was  calculated  that  the  pressure  of 
the  tubing  against  the  projecting  spur  would  press  it  back,  and  allow 
the  fseces  to  pass  round  the  corner  without  passing  out  of  the  artificial 
anus.     At  the  end  of  seven  weeks  nearly  all  the  faeces  passed  by  the 


U,  Upper.  L,  Lower  bowel.  I,  Faecal  fistnla. 
The  gut  is  uot  bent  very  aciitely  on  itself,  and 
there  is  no  spur.  The  opening  in  the  bowel  is 
usually  small  and  communicates  with  the  skin 
generally  by  a  sinus-like  track.  II.,  III.,  Artificial 
anus.  The  bowel  is  here  more  acutely  bent  and 
a  spur  is  present.  In  an  artificial  anus  the  open- 
ing communicates  more  directly  with  the  surface 
than  is  here  shown.  IV.,  Double  fjEcal  fistula. 
(Greig  Smith.) 


*  This  may  be  efEected  by  the  use  of  pressure-forceps,  as  suggested  by   Mr.  PauL 
Tlieir  use  is  given  at  p.  258. 


CLOSUKE  OF  F-ECAL  FISTULA.   ETC. 


277 


rectum  instead  of  by  the  artificial  anus,  this  being  reduced  to  a  sinus, 
giving  vent  to  a  few  drops  of  yellowish  fluid.  At  the  end  of  three 
months  this  completely  closed. 

Operation. 

Three  methods  will  be  mentioned,  i.  Here  the  peritonseal  sac  is  not 
opened.  The  margins  of  the  fistula  having  been  sufficiently  freed,  they 
are  pared  and  brought  together  with  silk  sutures  and  kept  apposed. 
Hare-lip  pins  may  assist  in  taking  off  the  tension.  This  method  can 
only  be  suitable  to  small  ftecal 

fistulie  where  the  exposure  of  Fig.  115. 

mucous  membrane  is    trifling  G    Efc 

and  no  spur  is  present.  It 
usually  fails  from  the  separa- 
tion of  the  edges  of  the  fistula 
not  being  free  enough,  owino- 
to  the  operator's  fear  of 
o])ening  the  peritona?al  sac. 
thus  causing  tension  on  the 
sutures. 

The  late  Mr.  Greig  Smith 
(Abdom.  Sunj..  p.  728)  spoke 
highly  of  the  following  opera- 
tion, which  may  be  used  both 
for  cases  of  fascal  fistula  and 
artificial  anus.  In  applying 
the  method,  however,  to  cases  of 
artificial  anus,  the  spur  must 
be  first  diminished  and  the 
lower  part  of  the  bowel  dilated 
to  some  extent.  In  order  to 
accomplish  this,  ^Lr.  Greig 
Smith  advises  the  introduction 
of  an  india-rubber  tube,  after 
Banks'  plan,  for  some  days 
before  the  operation  is  per- 
formed. 

Any  granulations  having 
been  scraped  away  and  the 
aperture  in  the  bowel  plugged 
by  a  sponge,  two  incisions  are 
made,  one  above  and  one  below 
the     fistula,     and    joined    by 

curved  incisions  which  include  the  fistula.  The  extra-peritongeal  fatty 
tissue  ha^-ing  been  reached,  the  parietal  peritonEeum  is  separated  from 
the  abdominal  wall  all  round  the  fistula  for  at  least  two  inches.  This 
step  will  be  best  carried  out  by  commencing  the  separation  at  the 
extremities  of  the  incisions  which  are  most  remote  from  the  fistula,  and 
working  towards  the  latter.  The  bowel  with  the  loosened  peritona?um 
can  now  be  lifted  out  through  the  incision  in  the  parietes.  If  there  is 
any  difficulty  in  doing  this,  a  little  more  detachment  of  peritonaeum 
will  make  it  easy.  The  fistulous  track  is  now  cut  away  down  to  the 
level  of  the  bowel,  and  the  opening  in  the  latter  closed  by  one  or  more 


Diagrams  to  show  Greig  Smith's  method  of  closiug 
facal  fistula. 

Fi,  Fistula  iu  abdominal  wall  communicating 
with  the  bowel.  G,  Granulations  lining  the  fwcal 
fistula.  S,  Skin.  M,  Muscvdar  laj-er.  F,  Sub- 
peritonaeal  tissue.  AD,  Adhesions  between  bowel 
and  peritonaeum  surrounding  the  fistula.  B.  Bowel. 

The  broken  line  in  the  upper  diagram  shows  the 
incisions  around  the  fistula  and  in  the  sub-peri- 
tonasal  areolar  tissue.  The  lower  diagram  shows 
the  operation  completed  and  the  sutures  placed. 
(Greig  Smith.) 


2/8  OPEEATIOXS  OX  THE  ABDOMEN. 

rows  of  Lembert's  sutures  inverting  the  rawed  edges  (Fig.  115).  The 
intestine  and  jjeritonsenni  are  now  replaced  and  the  parietal  incision 
closed,  with  the  exception  of  a  small  opening,  through  which  a  drain  is 
passed  down  to  the  sutured  gut. 

ii.  and  iii.  Here  the  peritonseal  sac  is  opened, 

ii.  Closure  of  the  opening  without  coniplete  resection  of  the 
bowel. — The  preliminary  steps  as  to  diet  and  treatment  of  the  ecze- 
matous  skin  given  below  (p.  279)  should  be  carefully  attended  to.  The 
following  account  is  taken  from  the  report  of  a  patient  under  mj^  care 
in  Guy's  Hospital  in  August  1895  : — 

At  an  operation  for  acute  intestinal  obstruction  due  to  bands,  a  gangrenous  patca 
had  been  found  in  the  ileum,  and  the  intestine  had  been  drained  through  a  Paul's  glass 
tube.  This  the  patient  pulled  out,  and  an  artificial  anus  resulted.  The  gut  was  plugged 
with  small  sponges  tied  on  silk  and  pushed  about  two  inches  above  and  below  the 
opening.  Two  curved  incisions  were  then  made  so  as  to  include  an  oval  three  inches 
and  a  half  long  and  an  inch  and  a  half  wide.  In  the  centre  of  this  lay  the  opening 
surrounded  by  the  usiial  eczematous  margin,  most  of  which  was  enclosed  by  the  above 
incisions.  The  incisions  passed  through  the  rectus  on  each  side.  After  the  posterior 
layers  of  the  sheath  had  been  reached  the  incisions  were  very  cautiously  deepened 
until  the  peritonaeum  was  reached.  In  opening  this  an  exploring  finger  was  introduced 
through  each  lateral  cut  so  as  to  make  certain  that  no  coils  of  intestine  were  adherent 
beneath.  The  finger  being  used  as  a  director,  the  peritoneum  was  cut  through  along 
the  lateral  incisions  in  their  whole  extent.  An  oval  island  of  the  tissues  forming  the 
abdominal  wall  was  now  set  free  and  could  be  drawn  forward  with  the  bowel  adherent 
to  it  below,  and  showing  the  sponges  which  had  been  introdiiced  as  plugs  bulging  out 
its  coats.  The  bowel  in  which  lay  the  artificial  anus  was  now  separated  from  adjacent 
coils  and  the  adhesions  which  bound  it  to  the  parietes,  partly  with  a  steel  director, 
partly  with  blunt-pointed  scissors,  used  at  one  time  closed  and  at  another  open. 
Sponges  and  iodoform  tampons  had  previously  been  packed  around  so  as  to  soak  up 
any  blood.  When  the  artificial  anus  had  been  separated  from  all  adhesions  it  was 
found  to  be  about  two  inches  and  a  half  long.  Its  edges  were  pared,  and  the  plugging 
sponges  having  been  removed,  the  opening  was  closed  with  a  double  silk  suture — first  a 
continuous  one  taking  up  all  the  coats,  and  then  a  row  of  Lembert's  securing  suflBcient 
inversion.  These  were  carried  well  beyond  the  actual  limits  of  the  opening  (Fig.  55, 
p.  228).  A  little  iodoform  having  been  rubbed  in  along  the  line  of  suture,  the  intestine 
was  returned.  A  few  tags  of  omentum  which  were  adherent  to  the  abdominal  wall  in 
the  vicinity  of  the  wound  were  detached  and  tied.  When  the  intestine  was  returned 
the  interior  of  the  abdomen  was  quite  free  from  all  blood  or  other  discharges.  The 
edges  of  the  wound  were  then  brought  together  as  far  as  possible,  but  this  was  only 
feasible  above  and  below.  In  the  centre  was  a  lozenge-shaped  gap,  measuring  two 
inches  and  a  half  long  by  an  inch  wide,  at  the  bottom  of  which  lay  the  sutured 
intestine.  The  gap  was  lightly  plugged  with  iodoform  gauze  wrung  out  of  carbolic 
acid  lotion  (i  in  20).  The  patient  made  a  good  recovery,  the  only  drawback  being  his 
weak  condition,  due  to  his  having  been  fed  so  long  (seventy-two  hours,  including  the 
time  before  and  after  the  operation)  by  enemata.  Flatus  was  passed  on  the  second 
day,  and  the  bowels  acted  well  two  days  later.  A  fortnight  after  the  operation  I 
placed  numerous  large  grafts,  cut  from  the  shoulders  by  Thiersch's  method,  on  the 
granulating  surface  which  represented  the  remains  of  the  oval  gap  in  the  parietes. 
All  was  soundly  healed  within  five  weeks  of  the  operation.  I  lost  sight  of  the  patient 
for  five  months,  when  he  returned  with  a -ventral  hernia.  This  he  attributed  to  his 
having  had  scarlet  fever,  and  to  the  pad  of  the  belt  with  which  he  had  been  supplied 
having  shrunk  after  the  baking  to  which  it  and  his  clothing  had  been  submitted.  He 
was  otherwise  in  excellent  health,  without  any  flatulence  or  constipation,  enjoying  his 
food  and  able  to  go  about  helping  his  father,  who  is  a  costermonger.  He  was  supplied 
with  a  new  pad.  If  the  hernia  increase,  it  wil],  I  think,  be  now  possible  to  pare  the 
edges  of  the  old  oval  gap,  and  to  bring  them  together,  a  step  quite  impossible  at  the 
time  of  the  operation. 


EXTEROPLASTY.  279 

iii.  Closure  of  the  Ai'tificial  Anus  with  complete  resection  of  the 
bowel. — If  this  step  be  needed  I  know  of  no  clearer  account  than  that 
of  Mr.  Makins  (St.  Thoinass  Hasp.  Bep.,  vol.  xiii.  p.  iS).  The  skill 
^\•ith  which  the  operation  was  carried  out  was  only  equalled  by  the 
thoughtfulness  with  which  it  was  planned. 

The  patient  was  21.  The  artificial  anus,  dating  to  a  hernia,  was  high  up  in  the 
small  intestine,  and  opened  about  an  inch  and  a  half  above  the  centre  of  Poupart's 
ligament.  Here,  at  the  bottom  of  a  small  pit,  the  mucous  membrane  of  the  intestine 
was  slightly  prolapsed.  The  gut  was  firmly  attached  :  the  finger  only  passed  into  the 
upper  opening ;  the  lower  could  not  be  found.  First,  the  usual  eczematous  condition 
was  very  much  improved  by  the  use  of  a  small  shield,  and  mopping  away  of  discharge 
with  absorbent  wool.  Xo  food  was  given  by  the  mouth  after  the  evening  of  the  second 
day  before  the  operation,  nutrient  enemata  being  given  every  four  hours.  During  the 
day  before,  the  upper  end  of  the  bowel  was  washed  out  with  injections  of  salicylic 
lotion.  As  bile-stained  fluid  wn.j  escaping  from  the  fistula  an  hour  before  the  operation, 
this  washing  out  was  repeated.  Before  beginning  the  operation  a  bit  of  carbolised 
sponge  attached  to  string  was  passed  for  two  inches  into  the  upper  end  of  the  bowel. 
A  vertical  incision  of  two  inches  and  a  half  being  made  through  the  abdominal  wall, 
the  upper  end  of  the  intestine,  normal  in  size,  was  dissected  free  from  its  adhesions  ;  the 
lower  end,  lying  just  below  it,  was  contracted  to  the  size  of  a  pencil,  with  an  opening 
only  large  enough  to  atlmit  a  director.* 

The  two  ends  of  the  gut  being  now  provisionally  clamped  with  forceps  (Fig.  94), 
sheathed  in  tubing,  they  were  draAvn  out,  and  a  number  of  sponges  attached  to  string 
packed  round  them.  The  sponge  Avas  then  drawn  from  the  upper  end  of  the  intestine, 
and  about  an  inch  removed  from  the  tipper  end  and  two  inches  and  a  half  from  the 
lower  one,  together  with  a  wedge  of  mesentery  four  inches  long  by  three-quarters  of  an 
inch  wide.  The  cut  surfaces  then  nearly  corresponded.  The  bleeding  points  having  been 
tied  in  the  mesentery,  this  was  united  with  six  silk  sutures,  and  the  gut  then  sutured 
as  follows  : — A  first  row  of  twenty-five  very  fine  Chinese-twist  stitches  were  passed  with 
a  small  curved  needle  through  the  whole  thickness  of  the  gut,  about  one-tenth  of  an 
inch  from  its  free  margin,  commencing  at  the  mesenteric  border.  These  were  tied  in 
batches  of  five  at  a  time.  Then  a  second  row  of  Lembert's  sutures  (Figs.  ^^  and  58) 
were  passed  and  tied  in  the  same  manner.  During  the  stitching,  which  took  about 
three-quarters  of  an  hour,  the  gut  was  kept  moist  with  warm  salicylic  lotion.  After 
the  bowel  was  closed  and  returned,  it  was  found  impossible  to  close  the  whole  wound. 
As  this  could  only  be  brought  together  above  and  below,  the  granulations  were  shaved 
away  and  the  intestine  left  at  the  bottom  of  a  deep  pit.  lodoform-gauze  and  pine- 
wood  dressings  were  applied.  The  patient  made  a  good  recovery.  Two  days  later  the 
intestine  could  be  seen  at  the  bottom  of  the  wottnd  covered  with  lymph  and  showing 
vermicular  movements.  The  bowels  acted  naturally  two  days  after  the  operation.  No 
f  ?eccs  came  by  the  wotmd,  but  twelve  sutures  were  thus  discharged. 


ENTEKOPLASTY. 

This  terra  has  been  given  to  an  operation  for  the  relief  (short  of 
resection)  of  strictures  of  the  intestine  believed  to  be  innocent.  It  is 
based  upon  a  similar  operation  performed  several  times  successfully 
upon  a  pylorus,  the  seat  of  contraction  not  due  to  malignant  disease, 
and  called  Pyloroplastv  (Fig.  123,  p.  313).  As  far  as  I  know,  Mr.  H. 
W.  Allingham's  two  cases  {Lancet,  vol.  i.  1894.  p.  1550)  are  the  only 
ones  yet  published.  One  such  stricture  occurred  in  a  woman,  aged  48, 
at  the  junction  of  the  ileum  and  jejunum,  the  other  in  the  sigmoid  of  a 

*  Over  two  months  had  elapsed  since  the  formation  of  the  fistula,  and  one  month 

since  the  last  proper  action  of  the  bowels. 


28o  OPERATIONS  ON  THE  ABDOMEN, 

patient  aged  73.  It  is  simply  stated  that  "the  stricture  was  innocent," 
and  "  not  malignant."  As  the  cases  were  published  within  two  months 
of  the  operation,  the  nature  of  the  stricture  must  remain  very  doubtful. 
The  age  of  the  patients,  the  position  of  one  in  the  sigmoid,  and  absence 
of  any  history  of  dysentery,  are  very  suspicious.  In  each  case  the 
stricture  was  divided  in  the  following  way :  The  bowel  having  been 
drawn  out,  shxit  off  with  sponges,  and  clamps  applied  above  and  below, 
the  bowel  and  stricture  were  divided  longitudinally  for  three  inches,  on 
the  side  of  the  gut  opposite  to  the  mesenteric  attachment.  Each  lip  of 
the  longitudinal  incision  was  then  caught  hold  of  at  about  its  centre, 
pulled  apart  so  that  at  first  it  gave  the  appearance  of  a  diamond-shaped 
opening,  and  then,  by  further  pulling  in  the  same  direction,  the  original 
longitudinal  incision  was  made  into  one  transverse  to  the  long  axis  of 
the  bowel.  The  opening  was  then  closed,  first  with  a  continuous 
suture  uniting  the  mucous  membrane,  and  then  by  Lembert's  inter- 
rupted sutures. 


CHAPTER  VI. 

OPERATIVE   INTERFERENCE   IN   GUNSHOT 

AND    OTHER    INJURIES    OF    THE    ABDOMEN. 

RUPTURE  OF  THE  INTESTINE. 

GUNSHOT    AND    OTHER    INJURIES. 

We  o\\'e  the  great  advances  lately  made  here,  in  the  first  place,  to 
antiseptic  surgery,  and,  in  the  second,  to  the  zeal  with  which  American* 
surgeons  have  taken  up  the  matter  and  made  known  their  results, 
unsuccessful  as  well  as  successful. 

1.  E.ccrniination  of  the  Wound,  vAth  reijard  to  Venetration. — Blacken- 
ing of  the  wound  and  the  clothes  with  powder  suggests  a  close  shot 
and  probable  penetration.  Edges  clean  cut  and  equally  stained  show 
tliat  the  bullet  has  struck  perpendicularly.  Unequal  staining  and 
raggedness  suggest  obliquity  of  impact;  and  the  less  perpendicular 
this  is,  the  less  the  probability  of  penetration.  If  there  exists  a  con- 
tinuous track  of  tenderness,  especially  if  accompanied  with  slight 
redness,  from  the  wound  for  some  distance  over  the  abdominal  surface, 
it  is  fair  to  infer  that  the  missile  has  wormed  itself  between  the  layers, 
without  penetration  (Parkes). 

2.  Sirniptoms  indicatin'j  Penetration. 

(a)  Circumscribed  dulness  and  bulging  near  the  wound,  fluctuation 
in  the  peritongeal  sac,  or  either  of  the  last  two  felt  per  rectum  or 
\aginam,  indicate  wound  of  a  large  vessel  and  accumulation  of  blood, 
and  penetration,  with  visceral  injury,  probably ;  but,  to  be  diagnostic, 
it  must  come  on  within  a  couple  of  hours.  (/Q)  Rapidlj^-formingf 
tympanites  indicates  penetration  and  escape  of  gas  from  the  intestine. 
(7)  Escape  of  faeces,  bile,  or  urine  from  the  wound  is,  of  course, 
diagnostic  of  penetration,  but  rare,  (h)  Repeated  haematemesis  in- 
dicates penetration  and  injmy  to  the  stomach  or  small  intestine  high 
up.  It  may,  however,  be  due  to  contusion,  (e)  Profuse  haemorrhage 
l)er  anum  points  to  penetration  and  injury  of  intestine,  but  is  seldom 
seen  sufficiently  early  to  be  of  value.     (^)  Htematuria  indicates  injury 

*  lu  additioa  to  the  American  writers  I  have  quoted  below,  I  have  had  the  advan- 
tage of  reading  a  very  careful  study  of  this  subject  by  my  old  dresser.  Dr.  J.  H. 
Barnard,  now  of  Paris,  I)es  Plaies  cle  V Intestine  par  Arvies-u-feu  (These  pour  le  Doctorat 
cu  Medecine,  Paris,  1887). 

t  If  delayed,  the  tympanites  may  be  due  to  paralysis  of  the  intcstiiies  from  shock. 


282  OPERATIOXS  OX  THE  ABDOMEN. 

of  some  part  of  the  iiriiiary  tract.  (?/)  Escape  of  blood  from  the 
wound,  if  too  profuse  to  be  accounted  for  by  a  wound  of  a  vessel 
in  the  abdominal  wall,  points  to  penetration  and  visceral  injury. 
(6)  Paralysis  of  any  part  below  the  level  of  the  wound  is  a  most  grave 
complication,  indicating,  as  it  does,  injury  to  cord  or  nerves,  as  well  as, 
probably,  to  viscera,  (t)  Shock.  This  does  not  go  for  much  unless 
heemorrhage  is  cleai'ly  present  also,  owing  to  the  great  difference  in 
individual  peculiarities. 

Other  points  will  be,  the  size  of  the  bullet  and  the  amount  of  fulmina- 
tive  or  powder,  the  distance  and  direction  in  which  the  firearm  was 
held.  A  single  opening  gives,  pe?-  se,  a  faint  hope  that  there  is  no 
penetration. 

In  cases  of  doubt  as  to  penetration,  the  wound  ^^•ill  be  first  enlarged, 
then  explored  with  a  probe  or  bougie,  and  the  line  of  damage  to  the 
tissues  carefully  followed  up,  any  exploring  instruments  being  kept 
strictly  aseptic. 

3.  Probable  Amount  of  Damage. — Dr.  Parkes  (Ann.  of  Surg.,  Nov. 
1887)  gives  the  following  suggestions: — "An  antero-posterior  shot 
below  the  level  of  the  umbilicus  and  well  towards  the  lateral  surfaces 
of  the  body  will  be  very  likely  to  miss  the  small  intestines  entirely, 
and  expend  its  damage  on  the  large  bowel.  The  same  kind  of  wound 
high  in  the  lateral  surfaces  may  pass  into  or  through  the  liver  without 
injuring  the  intestines,  or  the  spleen  alone  if  the  entrance  is  on  the 
left  side. 

"  If  the  wound  is  so  situated  that  the  bullet  enters  the  abdomen 
through  the  diaphragm,  adding  injury  of  abdominal  viscera  to  that  of 
the  contents  of  the  chest,  the  surgeon's  help  will  probably  be  of  little 
use.  A  wound  of  entrance  and  exit,  or  an  entrance  wound  alone, 
showing  passage  of  the  ball  from  side  to  side  through  the  abdomen, 
means  the  worst  of  injuries,  and  suggests  the  need  of  the  greatest 
care  in  staying  of  haemorrhage,  repair  of  intestines,  and  toilet  of  the 
contents. 

"  Antero-posterior  perforation,  if  complete,  can  only  fail  to  wound 
the  small  intestines  when  situated  well  on  the  outskirts  of  the  surface 
of  the  abdomen ;  seemingly  there  can  be  no  exception  to  this  proposi- 
tion, save  in  those  extremely  rare  instances  in  which  the  perforating 
body  traverses  the  cavity  without  injuring  the  contents. 

"  Penetration  through  the  posterior  walls  of  the  cavity,  if  complete, 
with  likelihood  of  laceration  of  important  fixed  organs,  argues  an  injury 
of  the  most  severe  character,  one  in  which  the  surgeon's  aid  will  be  of 
no  avail  in  the  majority  of  cases.  The  exceptions  in  which  the  severity 
will  not  prove  insurmountable  will  be,  transit  through  the  space 
between  the  lower  end  of  the  kidney  and  the  crest  of  the  ilium,  and  in 
wounds  occupying  the  outskirts  of  the  entire  posterior  surface.  .  .  . 
jNian}^  instances  are  recorded  of  recovery-  from  posterior  penetration 
of  the  large  and  fixed  viscera  of  the  abdomen  without  any  surgical 
operation.'' 

Question  of  the  Advisability  of  Operative  Interference. — Up  to 
the  time  of  the  Boer  War  these  wounds  were  considered  to  be  almost 
necessarily  fatal  if  an  abdominal  section  were  not  immediately  per- 
formed, death  resulting  usually  from  haemorrhage  or  from  septic 
peritonitis. 


GUNSHOT  AND  OTHER  INJURIES.  283 

The  results  of  alxlouiinal  wounds  produced  by  the  Mauser  bullet 
have,  however,  produced  practically  a  revolution  as  regards  the  question 
now  under  consideration.  For  it  has  been  found  that  these  injuries, 
when  not  immediately  fatal,  have  been  attended  with  remarkably  good 
results  under  expectant  treatment,  recovery  following  in  more  than 
60  per  cent,  of  the  cases,  according  to  Mr.  Spencer  (Med.  Ann.,  1901). 

Sir  F.  Treves  (Brit.  Med.  Journ.,  vol.  i.  1900.  p.  11 56)  mentions  cases 
in  which  the  abdomen  was  completely  traversed  in  various  directions,  and 
3^et,  in  spite  of  prolonged  exposure  and  tedious  transport,  recovery  took 
place  with  only  ver}^  slight  symptoms.  In  the  earlier  part  of  the  war 
he  describes  undertaking  several  abdominal  sections,  but  he  found  that 
he  was  doing  more  harm  than  good,  as  the  coils  of  intestine  already 
adhered  and  sealed  the  wounds,  there  being  no  prolapse  of  mucous 
membrane  or  escape  of  intestinal  contents.  Treves  concludes  that  it  is 
impossible  to  operate  in  cases  in  which  the  abdomen  is  traversed  above 
the  umbilicus,  owing  to  the  multiple  character  of  the  injuries  ;  whilst 
the  cases  in  which  the  abdomen  is  traversed  below  the  umbilicus  get 
well  without  operation.  He  advises  operation  only  when  the  bullet 
has  escaped,  and  so  its  course  is  known,  and  when  the  general  condition 
is  good  and  there  are  signs  of  abdominal  hsemorrhage  continuing. 

It  must  be  remembered,  however,  that  this  refers  only  to  wounds  pro- 
duced b}^  bullets  such  as  the  Mauser,  which  does  not  spread  on  impact, 
is  of  small  diameter,  and  has  a  great  velocity.  Where  the  bullet  produc- 
ing the  wound  is  one  which  causes  more  damage  than  the  Mauser,  the 
expectant  treatment  is  hardly  likely  to  be  successful,  and  in  such  cases 
it  is  certainly  justifiable  to  urge  as  early  an  operation  as  is  possihle,  after 
the  diagnosis  of  peritonceal  perforation  is  made.  The  exceptions  would 
appear  to  be — cases  where  sufficient  time  has  elapsed  to  allow  of  much 
extravasation,  and  the  onset  of  a  peritonitis  which  is  certain  to  be  fatal 
whatever  is  done ;  cases  of  injury  to  the  spinal  cord ;  severe  wounds  of 
the  solid  viscera ;  and  those  where  such  grave  collapse,  not  due  to 
haemorrhage,  is  present  as  to  make  it  certain  that  the  needful  inter- 
ference with  the  contents  of  the  abdomen  will  be  necessarily  fatal. 
With  regard  to  the  presence  of  peritonitis,  the  late  Mr.  Greig  Smith 
wrote  (loc.  supra  cit.,  p.  704) :  "  Undoubted  and  severe  peritonitis  existing 
on  the  second  and  third  da}^  is  by  most  authorities  recognised  as  a 
contra-indication.  In  such  cases  it  is  improbable  that  the  sites  of  perfora- 
tion could  be  found ;  and,  if  they  were,  that  they  could  be  dealt  with 
without  the  production  of  excessive  traumatism.  There  is  little  use 
in  cleansing  the  cavity  if  it  is  to  be  at  once  refilled,  and  there  is  little 
use  in  looking  for  the  perforations  if  they  can  neither  be  closed  nor 
fixed  in  the  wound.  ^A-hile  there  is  positive  danger  in  adding  to  the 
I'isk  from  traumatism.  In  such  cases  the  most  that  can  be  done  is  to 
make  a  small  parietal  opening  with  the  help  of  local  anaesthesia,  and 
])ermit  the  discharge  of  the  noxious  fluids,  giving  the  patient  the 
lienefit  of  the  remote  chance  of  spontaneous  cure  with  intestinal 
fistula."  * 

Prof.  Nancrede  (Ann.  of  Surg.,  June   1887,  p.  474)  thus  states  the 

*  Dr.  Barnard  (Jor.  .'n/jj/'a  cit..  p.  58)  quotes  Dr.  Hamilton,  of  New  York,  as  of 
opinion  that  operative  interference  is  contra-indicated  if  forty-eight  hours  have 
elapsed  since  the  accident. 


284  OPERATIONS  OX  THE  ABDOMEX. 

advantages  of  an  operation  : — ••  We  can  either  forestall  septic  peritonitis 
or  reduce  its  dangers  to  a  minimum ;  we  can  prevent  saprasmia — a  com- 
mon cause  of  death,  as  I  believe Should  peritonitis  have  set  in, 

Ave  can  afford  sufficient  drainage  for  the  effusions,  wliich  may  in  them- 
selves be  alreadv  poisonous,  or,  as  we  have  shown,  will  assuredh'  become 
the  chief  cause  of  danger  ;  we  can  substitute  for  adhesions  of  doubtful 
permanenc}'  certain  methods  which  secure  the  escape  of  the  injured 
portions  of  gut  into  the  lumen  of  the  bowel ;  we  can  prevent  the  fatal 
results  which  must  follow  the  casting  off  of  a  decomposing  slough  of  a 
wounded  portion  of  omentum  or  mesentery  into  the  general  peritonseal 
cavity;  we  can  arrest  haemorrhage,  which  from  its  amount  will  prove 
fatal,  or  from  decomposition  will  equally  produce  lethal  results ;  we  can 
restore  the  continuity  of  the  gut,  if  it  be  nearl}-  or  completely  severed, 
the  former  condition  being  not  uncommon ;  we  can  avoid  the  risk  of 
faecal  fistula  ....  and  we  can  remove  a  hopelessly  damaged  kidney  or 
spleen,  and  repair  a  wounded  pancreas  or  liver." 

Operation. — An  excellent  account  of  this  will  be  found  in  the 
very  helpful  article  of  Prof.  Xancrede  to  which  reference  has  been 
already  made. 

^\ith  the  utmost  care  the  preliminary  details  of  preparation  are 
entered  into  first — viz.,  the  cleaning  and  shaving  of  the  skin,  the 
pro\dding  of  abundance  of  water  recently  sterilised  by  boiling,  or 
a  2  per  cent,  solution  of  boracic  acid,  or  a  5  per  cent,  solution  of 
salicylic  acid.  Plenty  of  sterile  gauze  lying  in  the  hot  sterilised 
water,  to  cover  the  intestines  Avith.  Abundance  of  ligatures  of  gut 
and  silk,  of  different  sizes.  In  addition  to  the  usual  instruments 
several  pairs  of  Kocher's  clamps  should  be  at  hand,  or  strips  of  gauze 
may  be  passed  through  the  mesenteries  and  clamped  Avith  Spencer 
Wells's  forceps. 

"  Xow  as  to  technique.  The  patient's  limbs  and  trunk  must  be 
carefully  wrapped  in  blankets,  with  towels,  wrung  out  of  the  aseptic 
or  antiseptic  solution,  tucked  under  and  folded  over  them  around 
the  alDdomen  to  prevent  any  accidental  contamination  of  the  peri- 
tonseal   cavity.      If  not   previously   done,    the    urine    should   now    be 

drawn    off. Ether   should   be  most   cautiously  administered. 

The  incision  should  always  be  median,*  as  otherwise  it  is  almost 
impossible  to  gain  a  proper  view  of  the  parts,  and  should  usually 
extend  from  a  short  distance  above  the  umbilicus  to  about  t\vo 
inches  above  the  pubes.  The  abdomen  having  been  opened,  any 
clots  or  blood  which  obscure  the  operating  field  may  be  removed, 
but  otherwise,  unless  it  is  manifest  that  severe  hemorrhage  is  going 
on,  the  small  intestines.!  which  usually  first  present,  should  be 
carefully  gone  over,  inch  by  inch,  from  the  stomach  to  the  ileo-caecal 

'•'  This  point  has  been  much  disputed.  Xo  hard-and-fast  rule  should  be  made,  but  as 
a  rule  the  incision  should  be  median.  The  late  Mr.  Greig  Smith  pointed  out  that  the 
following  cases  require  it : — Cases  where  the  ball  has  crossed  the  middle  line,  entering 
at  one  side  and  passing  towards  the  other,  and  in  others  where  the  ball,  entering  near 
the  middle  line,  passes  either  directh'  backwards  or  in  an  uncertain  direction.  I  have 
alluded  to  this  matter  later  (p.  28S). 

t  Dr.  Barnard  (loc.  supra  cit.')  points  out  that  wounds  of  the  duodenum  are  very 
rarely  met  with,  and  that  wounds  of  the  upper  aspect  of  the  transverse  colon  and  of 
the  omentum  at  this  level  are  amongst  the  most  difficult  to  discover. 


GUNSHOT  AND  OTHER  INJURIES.  285 

valve,  keeping  them  constantly  enveloped  in  towels  wrung  out  of 
hot  water  (sterilised)  ;  afterwards  the  stomach,  spleen,  liver,  pancreas, 
large  bowel,  kidneys,  bladder,  omentum,  mesentery.*  and  abdominal 
vessels  must  be  examined.  I  do  not  mean  that,  if  various  wounds 
are  discovered,  say  in  the  small  intestine,  and  the  place  of  exit  of 
the  ball  from  the  abdominal  cavity,  all  in  such  relations  as  would 
absolutel}-  exclude  injury  of  the  stomach.t  liver,  kidneys,  spleen,  or 
bladder,  such  a  detailed  examination  should  be  made  —  far  from 
it,  for  ever}^  unnecessary  manipiTlation  is  injurious  ;  but  I  do  advise 
that,  rather  than  overlook  a  wound,  much  manipulation  which 
the  result  proves  to  have  been  unnecessary  had  better  be  made.  Of 
course  the  source  of  a  severe  haemorrhage  must  be  at  once  sought  for. 
and  any  wounds  of  the  hollow  viscera  ignored  for  the  time  being, 
care,    however,   being   taken   that    the    general    peritonaeal    cavity   is 

*  "Wounds  of  the  mesenteiy,  when  they  are  but  perforations,  can  be  passed  without 
any  additional  interference,  unless  attended  with  hasmorrhage.  in  which  case 
deligation  of  the  injured  vessel  is  required.  Large  lacerations  should  be  closed  with 
a  running  suture  to  avoid  the  future  possibility  of  an  incarceration  and  obstruction  of 
a  loop  of  the  intestine  in  the  opening.  On  account  of  the  extreme  delicacy  of 
the  membrane,  its  closure  is  often  attended  with  some  difficulty,  which  may  be 
frequently  overcome  by  introducing  the  sutures  near  the  edge  of  a  vessel,  as  this 
region  affords  the  strongest  grasp  for  the  suture  "  (Shackner,  loc.  supra  cit.').  If  it  be 
the  omentum  which  is  wounded,  or  contains  a  large  hfematoma,  it  should  be  ligatured 
and  cut  away. 

t  Cases  of  wounds  of  all  these  viscera  have  been  treated  by  laparotomy  and  suture. 
Thus,  Mr.  Dalton,  of  St.  Louis  (Ann.  of  Sitrr/..  Aug.  1888).  records  a  case  of  bullet- 
wound  of  stomach  and  liver  thus  treated  successfully.  The  wounds  in  the  stomach 
were  those  of  entrance  and  exit,  and  situated,  the  former  on  the  anterior  surface,  the 
latter  near  the  upper  border;  both  were  closed  with  Lembert's  sutures.  The  lower 
margin  of  the  left  lobe  of  the  liver  was  ploughed  through  by  the  bullet  an  inch  and  a 
quarter  from  the  transverse  fissure,  leaving  a  V-shaped  wound  half  an  inch  in  depth. 
This  was  closed  by  one  catgut  suture,  of  large  size,  passed  on  either  side,  an  inch  from 
the  margin  of  the  wound,  and  dipping  deeply,  on  account  of  the  great  friability  of  the 
tissue,  into  the  liver  substance.  ••  It  acted  well,  bringing  the  wound  together  snugly." 
There  were  no  other  injuries  save  a  slight  contusion  on  the  transverse  colon,  probably 
due  to  the  spent  violence  of  the  ball,  which  was  not  found.  The  operation  was 
rendered  difficult  by  repeated  vomiting  of  black  grumous  fluid,  necessitating  turning 
the  patient  on  his  side  each  time,  "  which  was  awkward  with  an  open  belly."  The 
operation  was  a  prompt  one — two  hours  after  the  injury ;  recovery  followed.  In  Dr. 
Keen's  case  (^Mcd.  Nc?vs,  May  14,  1887)  the  wound  of  entrance  in  the  stomach  was  near 
the  pylorus  on  the  anterior  surface,  that  of  exit  much  more  difficult  to  find,  being  on 
the  lower  border  and  posterior  surface,  and  obscured  by  clot.  Though  there  were  other 
most  serious  injuries  of  superior  mesenteric  vein  and  right  kidney  requiring  nephrec- 
tomy, the  patient  survived  till  the  fifteenth  day,  death  being  due  to  diffuse  suppura- 
tion of  the  clot  in  the  mesentery,  and  gangrenous  perforation  at  one  spot  in  the 
intestine.  Other  means  of  meeting  hfemorrhage  from  the  liver  are  plus^ing  with  a 
tampon  of  aseptic  gauze  when  the  wound  is  large  and  the  hsemorrhage  great,  and 
applying  firm  pressure,  and,  in  the  case  of  obstinate  oozing  from  an  abrasion,  the 
application  of  a  crystal  of  iron  persulphate,  or  the  Paquelin's  caiitery.  Wounds  in  the 
gall-bladder  are  treated  like  those  of  intestine.  Wounds  of  the  kidney  or  spleen  must 
be  treated,  according  to  their  nature,  either  by  styptic,  cauterj'.  or  suture,  as  in  the 
liver.  If  the  haemorrhage  is  too  severe  for  the  above,  the  organ  must  be  removed. 
Dr.  Keen,  in  his  case  alluded  to  above,  the  kidney  being  badly  lacerated,  adopted 
this  step.  The  ureter  should  be  examiucd,  and,  if  found  divided,  sutured,  or  failing 
this  the  kidney  should  be  removed. 


286  OPERATIONS  ON  THE  ABDOMEN. 

protected  from  fa3cal  extravasation  by  removing  the  intestines  out- 
side tlie  abdomen,  keeping  them  wrapped  in  warm,  moist  cloths; 
such  hemorrhage  is,  however,  most  unusual.  "Whichever  plan  is 
pursued,  let  everything  be  done  methodically,  and  each  injury  re- 
paired as  it  is  detected,  as  this  saves  much  time  and  renders  any 
oversight  almost  impossible.  All  wounds  of  the  bowel,  however 
trivial,  should  be  minutely  cleansed,  coaptated  by  the  Lembert  suture 
of  fine  silk  introduced  with  an  ordinarj^  sewing-needle,  and  the  suture 
line  rubbed  over  with  a  little  iodoform.*  When  necessary  from  the 
size  or  number  of  the  wounds,  a  portion  or  whole  calibre  of  the  gut 
must  be  exsected.f  Wounds  of  the  liver,  if  situated  at  the  free  boi'der 
of  the  organ,  should,  if  possible,  be  coaptated  with  dry  aseptic  gut,  which 
will  soon  swell  and  fill  the  track  made  by  the  needles.  If  this  cannot  be 
done,  the  haemorrhage  ma}^  perhaps  be  arrested  by  the  judicious  use 
of  the  thermo-cautery.  Unless  the  bleeding  be  free,  the  wound  should 
be  plugged  with  an  iodoform-gauze  tampon,  which  is  to  remain  for 
forty-eight  hours,  or  may  perhaps  be  carefully  removed  at  the  close 
of  the  operation,  when,  if  the  bleeding  be  almost  entirely  checked, 
the  cauterj^  may  be  used  as  a  further  precaution :  if  the  flow  be  free, 
the  tampon  must  be  replaced  and  allowed  to  remain. 

"Wounds  of  the  pancreas,  spleen,  or  kidneys  must  be  treated  in 
a  similar  manner,  or,  if  these  measures  fail,  either  spleen  or  kidney 
must  be  excised.  Since  a  wounded  splenic  artery  would  lead  to 
gangrene  of  the  organ,  it  must  be  removed.  The  same  advice  holds 
good  for  wound  of  a  renal  artery,  but  in  these  cases  death  from 
hasmorrhage  will  usually  result  before  art  can  intervene  ;  still,  such 
possible  complications  must  be  pi'ovided  for.  Wounds  of  the  bladder 
had  best  be  sewn  with  dry  chromic  and  sulphurous  acid  gut,  which, 
by  its  swelling,  will  fill  the  track  of  the  little  wounds;  and  the  needle 
should  be  a  round  one,  as  small  as  can  be  made  to  carry  the  thread. 
Contused  bowel  will  almost  certainl}^  slough,  so  that  the  injured 
portion  had  better  be  excised  and  the  healthy  periton^eal  surfaces 
united  by  suture.  Wounded  or  contused  omentum  or  mesentery 
must  also  be  excised,  and  the  edges  carefully  united  by  inter- 
rupted sutures.  The  experience  of  at  least  one  case  has  shown  that 
since  an  omental  slough  cannot  be  eliminated  into  the  lumen  of 
the  bowel,  as  occurs  in  wounds  of  the  intestine,  a  fatal  generalised 
peritonitis  will  result  from  the  local  gangrene.  All  bleeding  must 
be  checked,  even  from  the  smallest  vessels,  for  cjuite  extensive  oozing 
will  occur  from  most  insignificant  vascular  orifices,  because  they  are 
situated  in  a  closed  cavity,  and,  although  the  amount  lost  may  not 
be  dangerous  per  se,  it  will  prove  so  as  a  source  of  septicaemia  or 
peritonitis." 

This  was  so  in  Dr.  Keen's  case   {loc.  siqrra  cit.).     The  haemorrhage 


*  Wherever  possible,  the  sutures  should  be  introduced  parallel  with  the  long  axis  of 
the  intestine,  as  by  this  its  lumen  is  least  narrowed. 

f  Of  all  the  wounds  of  the  intestine  those  of  the  rectum  are  most  difficult  to  detect, 
and  therefore  very  fatal.  Dr.  Morton  Qloc.  supra  rif.')  suggests  that  inflation  with  a 
rubber  bag  may  be  of  assistance  here.  He  also  alludes  to  two  cases  in  which  the 
diaphragm  was  wounded.  In  each  case  a  hernia  of  viscera  into  the  thorax  existed  ; 
this  was  reduced,  the  wound  sutured  with  catgut,  and  recovery  ensued. 


GUNSHOT  AND  OTHER  INJURIES.  287 

here  extended  fan-shaped  in  a  moderately  thick  Layer  between  the 
two  layers  of  the  mesentery,  its  periphery  extending  almost  two  feet 
along  the  bowel,  and  its  point  being  at  the  mesenteric  attachment 
to  the  spine.  The  chief  bleeding  came  from  a  hole  in  the  superior 
mesenteric  vein,  and  was  secured,  after  much  difficulty,  by  a  laterally 
placed  ligature  of  chromic  gut.  In  spite  of  the  most  careful  antiseptic 
precautions  and  unremitting  after-treatment,  the  patient  died,  on  the 
fifteenth  day,  of  suppuration  in  this  clot,  and  gangrene  of  the  intestine 
connected  with  this  part  of  the  mesentery.  Wounds  of  the  spleen 
must  be  treated  by  the  methods  already  given  for  the  liver  and 
kidney.     The  treatment  of  those  in  the  bladder  is  given  fully  later. 

"If  a  segment  of  bowel  is  to  be  excised,  the  cuts  should  be  made 
at  such  points  as  correspond  to  the  distribution  of  a  large  mesenteric 
branch  in  order  to  secure  a  due  blood-supply  to  the  edges  of  the 
incisions,  and  the  parts  to  be  removed  should  be  laid  upon  a  large 
flat  sponge,  or  folded  napkins,  to  prevent  feecal  extravasation  into 
the  abdominal  cavity.  To  avoid  escape  of  faeces  during  excision  of 
intestine,  the  simplest  of  all  clamps  is  small  rubber  tubing  made 
to  pierce  the  mesentery  on  each  side  of  the  wound,  at  a  spot  devoid 
of  vessels,  passed  round  the  intestine,  and  knotted  once,  or,  better, 
clamped  with  Spencer  AYells's  forceps  (Dr.  Shackner,  Ann.  of  Siinj.. 
June  1890).  To  obviate  kinking  of  the  bowel,  a  V-shaped  piece  of 
the  mesentery  must  be  removed,  the  branches  of  the  V  not  corre- 
sponding to  the  cut  edges  of  the  bowel,  but  presenting  a  free  margin 
of  one-eighth  of  an  inch,  lest  want  of  vascularity  cause  failure  of 
union  at  this  the  most  doubtful  point.  After  arresting  hfemorrhage, 
the  mesenteric  wound  must  be  carefully  coaptated  by  numerous 
points  of  interrupted  suture.* 

'•  Should  the  pulse  fail  at  any  time  during  the  operation,  owing  to 
irritation  and  paresis  of  the  abdominal  sympathetic,  flushing  the 
intestines  and  peritonajal  cavity  with  hot  water  will  often  at  once 
remove  the  unfavourable  condition.  The  most  scrupulous  care  must 
be  exercised  in  the  peritona?al  toilet,  which  can  be  luost  quickly  and 
effectively  made  by  thorough  irrigation  of  the  cavity  with  warm 
sterilised  water,  and  subsequent  careful  removal  of  all  fluid  in  the 
ordinary  manner  by  sponges,  especial  attention  being  paid  to  the 
case  of  the  pelvis  and  the  renal  regions. 

••  When  possible,  the  peritoneum  should  be  united  over  the  orifices 
of  entrance  and  exit  of  the  ball.t  and  a  little  iodoform  rubbed  in 

"  AVhen  incipient  peritonitis  exists  at  the  time  of  operation,  with 
the  probable  formation  of  large  quantities  of  acrid  septicaemia  or 
saprasmia  inducing  serum,  drainage  should  in  all  cases  be  instituted. 
....  The  tube,  preferably  of  glass,  should  have  its  end  kept  well 
down  between  the  bladder  and  rectum  in  the  male,  or  in  Douglas's  cul- 
de-sac  in  the  female,  with  the  external  orifice  plugged  with  iodoform 
cotton." 


*  Where  the  security  of  the  suturing  of  a  severe  wound  of  intestine  is  doubtful, 
Dr.  Seun's  plan  of  giving  support  by  attaching  a  piece  of  omentum  should  be  used 
(p.  267). 

t  If  the  track  of  the  ball  is  likely  to  be  septic,  it  should  be  treated  by  incision, 
cleansing,  and  drainage. 


288  OPERATIONS  ON  THE  ^ABDOMEN. 

As  many  of  the  above  points  must  be  considered,  till  nioi'e  cases  give 
ns  better  ligbt,  still  suh  jvdice,  I  have  added,  for  contrast,  the  views  of 
another  American  surgeon.  Dr.  McGraw,  of  Detroit  [Trans.  Amer.  Surg. 
Assoc,  May  1889J.  It  will  be  seen  that  in  some  most  important  points 
— e.r/.,  the  site  of  the  incision  and  the  cjuestion  of  how  best  to  examine 
the  intestines — they  are  directlv  opposed  to  those  of  Dr.  Nancrede. 
Dr.  McGraw's  chief  propositions  are  as  follows: — 

a.)  Bullets  which  enter  the  abdominal  cavity  pass  in  a  nearly  abso- 
lutely straight  line  from  the  orifice  of  entrance  to  that  of  exit,  or 
their  final  stopping-place  in  the  viscera,  (ii.)  An  incision  made 
directly  in  the  course  of  the  ball  will  give  the  shortest  route  to  the 
injured  parts.  If  balls  pass  through  the  abdomen  in  straight  lines, 
a  cut  over  the  path  of  a  ball  will  open  the  nearest  possible  way  to 
the  wound  underneath,  provided  the  viscera  have  not  shifted  their 
2:)laces  since  the  shooting.  Even  then  they  could  be  easily  brought 
into  the  wound  for  the  purpose  of  repair.  Coils  of  viscera  which 
could  not  be  so  brought  could  not  possibly  have  been  struck  by 
the  ball,  (iii.)  If  a  gunshot  wound  of  the  intestine  will  not 
under  pressure  permit  discharge  of  its  contents,  it  has  been 
closed  by  the  eversion  of  the  mucous  membrane  or  by  the  exudation 
of  plastic  lymph.  In  either  case  the  wound  would  probably  recover 
without  suture  if  kept  perfectly  aseptic,  and  if  the  bowels  are  kept 
perfectly  cjuiet.  (iv.)  An  empty  condition  of  the  alimentary  canal 
is  most  favourable  for  healing.  To  secure  this  as  far  as  possible,  it 
may  be  proper,  in  some  cases  of  injury  of  the  bowel  after  a  hearty 
meal,  to  evacuate  the  stomach  by  a  syphon.  This  would  be  especially 
indicated  in  wounds  of  the  stomach,  duodenum,  and  upper  part  of  the 
jejunum,  whether  the  surgeon  does  or  does  not  decide  on  operative 
treatment.  In  small  wounds  of  the  stomach  and  duodenum,  suture 
may  sometimes  be  omitted  if  the  surgeon  can  be  assured  that 
these  viscera  are  empty,  (v.)  Senn's  method  of  hydrogen-gas  in- 
sufflation {supra,  p.  188).  however  admirable  in  recent  cases,  should 
be  used  with  great  caution  after  the  lapse  of  a  few  hours.  The  dis- 
tension and  motion  of  the  gut  caused  by  the  insufflation  might 
rupture  inflammatory  adhesions,  break  open  intestinal  wounds  that 
had  nearly  healed,  and  make  general  a  peritonitis  which  had  become 
circumscribed,  (vi.)  The  dangers  of  the  operation  are  directly  in 
proportion  to  its  length  and  to  the  amount  of  evisceration.  The 
length  of  an  operation  ma}'  be  lessened — (i)  By  strictly  limiting 
the  examination  of  the  viscera  to  such  of  them  as  may  have  been 
in  the  course  of  the  ball.  (2)  By  suturing  wounds  in  the  gut- 
wherever  it  is  possible,  instead  of  excising  them.  The  latte^r  should 
be   reserved    for   wounds    that   do   not   permit  inversion  and    suture. 

(3)  By  omitting  all  operative  procedures,  even  suture,  in  all  wounds 
which  have  become  so  thoroughly  occluded  b}'  plastic  material 
that    the    contents    of  the    bowel    cannot   be    passed   through    them. 

(4)  When  manj"  wounds  occur  near  together,  by  operating  first  on  those 
wounds  which  imperatively  demand  it,  and  leaving  to  the  last  those 
\\hich  may  recover  without  operation.  If  the  stomach  and  intestine 
are  both  perforated,  the  small  intestine  should  be  first  attended  to,  as 
the  stomach,  if  empty,  may  recover  without  suture.  So,  too.  large 
wounds    should    be    sutured    before    small    ones,  discharging    wounds 


GUNSHOT  AXD   OTHER   INJURIES.  289 

before  those  which  are  occhided.  (5)  By  never  turning  out  all 
the  intestines  except,  first,  when  hfemorrhage  is  otherwise  uncon- 
trollable :  or,  second.  Avhen  there  is  evidently  a  discharging  wound 
which  cannot  otherwise  be  found.  "  The  examination  of  the  whole 
intestine  by  slipping  it,  from  one  end  to  the  other,  through  the  fingers, 
though  not  causing  the  exposure  of  evisceration,  nevertheless  con- 
sumes an  enormous  amount  of  time,  and  reduces  very  materially 
the  sti'ength  of  the  patient.  In  my  opinion,  surgeons  have  exagge- 
rated the  difficulties  in  the  way  of  discovering  wounds  which  have 
made  this  procedure  necessary.  The  incision  over  the  course  of 
the  ball  will  aid  materially  in  the  diagnosis  by  exclusion,  for  no  in- 
testine which  cannot  be  brought  into  the  path  of  the  missile  could 
possibly  have  been  hit  by  it.  It  is  not  probable  that  a  gut  would 
slip  more  than  three  or  four  inches  away  from  the  place  it  occupied 
when  wounded,  and,  with  the  incision  I  have  mentioned,  the  necessity 
would  rarely  occur  of  examining  any  other  viscera  than  those  in 
the  immediate  neighbourhood  of  the  wound.  Let  us  suppose  that 
a  surgeon  in  operating  has  repaired  all  the  wounds  he  has  been 
able  to  find  in  or  near  the  course  of  the  ball :  he  has  washed  out 
the  abdominal  cavity  :  he  has  with  his  hands  gently  pressed  upon 
all  the  viscera  which  could  possibly  have  been  injured,  and  his  hands 
have  come  out  unstained  ;  he  has,  furthermore,  with  soft  sponges 
wiped  out  the  lower  part  of  the  abdominal  cavity  "svithout  finding 
blood  or  faeces.  Shall  he  then,  without  any  evidence  whatever  of 
an  additional  wound,  subject  his  already  exhausted  patient  to  a  most 
dangerous  procedure  on  the  mere  suspicion  that  there  might  be  a 
still  undiscovered  wound  ?  " 

It  will  be  seen  that  the  diversity  of  opinion  as  to  the  site  of  the 
incision,  and  the  desirability  of  turning  out  all  the  intestines  for 
examination,  turns  on  the  question  of  how  best  all  injuries  of  the 
peritona?al  sac  can  be  detected.  The  advocates  of  the  latter  step 
and  median  free  incision  claim  that  by  this  alone  can  the  needful 
inspection  be  made  of  all  the  viscera,  both  free  and  fixed,  hollow  and 
solid ;  they  point  to  numerous  cases  in  which  even  by  this  means  of 
complete  examination  injuries  have  been  overlooked  that  have  marred 
the  success  of  an  otherwise  complete  and  most  hopeful  operation ; 
they  hold  that  the  median  incision  alone  will  meet  those  cases  where 
the  course  of  the  ball  is  not  direct,  but  erratic,  or  where,  by  moving 
the  patient  a  long  distance,  or  from  peritonitis  setting  in  late,  peristalsis 
has  altered  the  position  of  the  bowels.  Till  we  have  more  cases 
to  guide  us.  I  think  the  published  e%'idence  shows  clearly  that  the 
median  incision  is  the  wiser,  save  in  a  few  cases,  as  where  the  wound 
lies  well  away  to  one  side,  as  here  the  colon  may  be  found  shot  through, 
and  only  this  organ  and  the  contiguous  small  intestine  and  the  kidney 
beliind  will  require  examination.  It  must  not  be  forgotten  that  with 
rhe  great  advantage  of  more  complete  exploration  which  the  median 
incision  affords  goes  the  greater  risk  of  shock  and  of  general  contamina- 
tion of  the  peritonteal  sac,  as  coils  which  are  possibly  leaking  are 
drawn  up  into  the  wound.  This  will  have  to  be  met  by  careful  irriga- 
tion later.  With  regard  to  turning  out  all  the  intestines,  the  advocates 
of  this  plan  claim  that  by  this  alone  can  all  the  wounds  be  found,  and 
that  this  step,  by  the  more  rapid  searching  which  it  allows,  in  reality 
VOL.  11.  ■  19       * 


290  OPEEATIONS  OX  THE  ABDO^^IEX. 

diminishes  shock.  Till  more  cases  have  been  published — and  surgeons 
owe  a  great  debt  to  the  candour  and  fulness  with  which  the  American 
surgeons  have  made  known  their  failures  as  well  as  their  successes — 
each  case  must  be  decided  on  its  merits.  The  points  which  will  aid  the 
surgeon  in  coming  to  a  decision  on  tiie  above  two  steps  are  any  obliquity 
of  the  wound  of  entrance,  and  of  the  course  of  the  ball ;  the  position  of 
the  wound  of  entrance,  whether  near  the  middle  or  the  lateral  parts  of 
the  abdomen ;  any  evidence  of  its  having  passed  from  side  to  side ; 
entire  uncertainty  as  to  its  course  ;  the  time  that  has  elapsed  since 
the  injury ;  the  interval  between  this  and  the  last  meal ;  and  whether 
the  patient  has  been  kept  quiet. 

In  cases  where  the  presence  of  multiple  wounds,  or  the  severity  of 
one,  entails  the  risk  of  sloughing,  or  where  multiple  suturing  will 
produce  dangerous  stenosis,  resection  must  be  pei'formed  on  the  lines 
already  fully  given  at  pp.  259,  263.  Two  very  interesting  cases  are 
recorded  by  American  surgeons,  in  which  Murphy's  button  was 
employed  successfully.  In  one  (Dr.  G.  F.  Wilson,  Ann.  of  Surg., 
Sept.  1895),  after  one  wound  of  the  ileum  had  been  found,  and 
closed  with  Lembert's  sutures,  eight  other  openings  were  found,  at 
a  considerable  distance  from  the  first,  three  being  very  close  together. 
Again,  some  little  distance  further  off,  the  bullet  had  passed  through 
the  mesenteric  border  of  the  intestine,  so  interrupting  the  blood- 
supply  that  a  slough  would  surely  have  resulted.  A  single  resection 
was  accordingly  determined  on,  and  the  portion  removed  measured 
without  stretching,  just  forty-three  inches.  The  patient  recovered,  and 
the  button  was  passed  on  the  ninth  day.  In  the  second  case  (Dr.  J. 
W.  Walker,  Ann.  of  Snrg.,  Jan.  1896),  a  resection  of  two  inches  of 
the  ileum  was  successfully  performed.  The  button  was  here  passed 
on  the  fifteenth  day.  As  Dr.  Walker  remarks,  if  Murphy's  button' 
be  used  at  one  place  and  another  wound  require  suture  lower  down^ 
any  unavoidable  constriction  which  the  latter  may  occasion  will 
cause  anxiety  as  to  the  safe  passage  of  the  button. 

The  chief  points  in  the  after-treatment  are — rectal  feeding  for  forty- 
eight  hours  or  longer  if  the  stomach  or  upper  part  of  the  intestine  has 
been  injured  ;  periodic  emptying  of  the  drainage-tube  with  a  syringe, 
or  even  irrigation  through  it ;  morphine  injections,  combined  with 
atropine  (about  ^V  gr.),  for  the  first  thirty-six  or  forty-eight  hours, 
rather  than  opium ;  cold  to  the  abdomen  by  means  of  an  ice  coil ; 
careful  use  of  saline  aperients — e.g.,  Seidlitz  powders — a  little  later. 

I  append  the  following  as  instances  of  what  injuries  the  surgeon  may 
expect  to  have  to  deal  with : — Bullet  wound  near  umbilicus ;  seven 
openings  in  alimentaiy  canal,  viz.,  three  openings  close  together  in  the 
small  intestine  (three  and  a  quarter  feet  below  the  duodenum),  two  open- 
ings in  the  descending  colon,  and  two  in  the  rectum:  no  great  extrava- 
sation ;  also  a  large  vein  wound  in  the  mesentery :  death  from 
peritonitis  ;  bullet  found  near  ischial  spine  (Annandale.  Lancet,  April 
15,  1885).  Pistol  wound  near  navel:  seventeen  hours  later,  operation 
(two  pints  of  bloody  serum  let  out,  with  small  clots,  but  no  faeces) ;  seven 
penetrating  wounds  of  intestine,  six  in  the  small,  one  in  the  sigmoid 
containing  the  bullet :  all  the  openings  plugged  with  ragged,  everted 
mucous  membrane ;  no  faecal  escape  till  edges  were  separated  ;  careful 
suturing  and  toilet ;  recover}-  after  a  very  critical  condition  for  a  week 


RUPTURE  OF  THE  INTESTINE.  291 

(Bull,  An7i.  of  Surg.,  May  1885).  Bullet  entrance  close  to  navel  : 
operation  two  hours  later ;  abdominal  cavit}^  full  of  blood  ;  a  spurting 
artery  in  the  niesenter}-;  eleven  wounds  requiring  suture  in  small 
intestine,  and  two  in  ascending  colon ;  no  faBcal  extravasation,  but  a 
melon-seed  body  found  and  removed ;  on  the  thirteenth  day  great 
rectal  tenesmus  led  to  discoveiy  of  blood-effusion  in  pelvis  ;  three 
pints  let  out  by  incision  about  two  inches  within  anus ;  recovery  ; 
bullet  passed  per  anum  (Hamilton,  Journ.  Amer.  Med.  Assoc,  Aug. 
22,  1885  ;  Ann.  of  Surg.,  Nov.,  1 885).  Bullet  entrance  three  and  a 
half  inches  above  umbilicus,  and  just  to  left  of  middle  line :  operation 
within  twenty-four  hours  ;  rent  in  omentum  close  to  great  curvature 
of  stomach,  and  t\A'o  linear  rents  in  this  viscus.  found  with  much 
difficulty ;  operation  had  to  be  concluded  quickly  fi'om  patient's  critical 
condition ;  death  from  acute  peritonitis  within  a  few  hours ;  four 
wounds  found  in  upper  part  of  jejunum,  all  within  a  distance  of  three 
inches  (Briddon,  New  York  Surg.  Soc,  Dec.  8,  1886;  Ann.  of  Surg., 
April  1887).  Bullet  wound  two  inches  above  and  two  inches  inside 
right  anterior  superior  spine  :  operation  in  nine  hours  ;  wound  found  in 
ascending  colon,  pouring  out  faeces ;  another  wound  in  colon,  also 
pouring  out  faeces ;  both  sutured ;  recovery  (McGraw,  Chicago  Med. 
Journ.  and  Exam.,  July  1887;  Ann.  of  Surg.,  Dec.  1887). 

A  very  complete  table,  containing  234  cases,  is  given  by  Dr.  T.  S.  K. 
Morton  (Journ.  Amer.  Med.  Assoc,  Jan.  4,  1890);  others  by  Sir  W. 
MacCoi'mac  and  Mr.  Barker  will  be  found  in  the  Brit.  Med.  Journ., 
May  II,  1887,  and  March  17,  1888. 

More  recent  papers  will  be  found  in  the  Annals  of  Surgery.  One 
of  the  most  interesting  is  by  Dr.  A.  B.  Miles  (vol.  ii.  1893,  P-  623). 
Thirteen  cases  are  given,  with  five  recoveries.  In  proof  of  the  severity 
of  these  cases,  of  the  recoveries  one  patient  had  sixteen,  another  four- 
teen, and  a  third  ten  wounds  of  the  small  intestine.  One  of  the  fatal 
cases  was  due  to  the  discharge  of  both  barrels  of  an  ordinary  shot-gun 
into  the  right  iliac  fossa. 


RUPTURE    or    THE    INTESTINE. 

The  following  remarks  are  taken  from  the  Cartwright  Prize  Essay  by 
Dr.  B.  F.  Curtis,  of  New  York  {Amer.  Journ.  Med.  Sci.,  Oct.  1887): 
Relative  frequency  of  rupture,  in  113  cases. — Duodenum,  6;  jejunum, 
44;  ileum,  38;  "other  parts  of  small  intestine,"  21  ;  large  intestine, 
4.  While  the  duodenum  and  large  intestine  escape  from  their 
sheltered  position,  the  jejunum  is  most  frequently  ruptured  in  its 
first  three  feet,  the  ileum  in  its  last  three.  Faecal  extravasation 
is  almost  invariably  present.  The  most  frequent  and  important  com- 
plication of  ruptured  intestine  is  laceration  or  contusion  of  the 
mesentery  ;  this  is  important  from  the  rapidly  fatal  haemorrhage,  or 
later,  gangrene.  The  cases  of  ruptured  intestine  fall  clinically  into 
three  classes.  (A)  The  shock  never  leaves  the  patient,  may  never 
lessen,  but  pass,  rapidly  or  slowly,  into  fatal  collapse.  This  may  be 
due  to  (i)  the  shock  of  the  accident;  (2)  to  haemorrhage  ;  (3)  to  fa?cal 
extravasation.  (B)  Those  in  which  evident  peritonitis  develops.  The 
diagnosis  is  easiest  in  these  cases,  but  unfortunately  thej'  are  not  the 


292  OPEEATIONS  OX  THE  AIJDOMEN. 

most  common.  (C)  The  most  common.  Instead  of  evident  peritonitis 
setting  in  after  reaction  has  taken  place,  vague  symptoms  appear,  keep- 
ing the  surgeon  in  expectation  of  it,  but  giving  nothing  on  which  he 
can  found  a  positive  diagnosis,  for  the  same  slight  indications  are 
common  in  cases  in  which  ultimate  recovery  has  taken  place.  Patient 
is  apathetic,  seemingly  satisfied  with  his  condition,  and  thus  mis- 
leading ;  or,  getting  gradually  weaker,  and  therefore  being  less  able  to 
complain,  appears  to  be  improving.  Peritonitis  in  this  group  of  cases 
develops  so  slowly  that  its  beginning  cannot  be  noted.  Duration  of 
life. — The  average  taken  from  1 1 3  cases  is  forty-eight  hours.  Chief 
points  in  the  diai/nosis  of  rupture  of  intestine. — Cause,  e.g.,  a  kick. 
This  was  so  in  28  per  cent,  of  the  cases.  The  intestine  is  crushed 
between  the  spine  and  the  force  employed.  The  severer  the  injury — 
e.r/.,  a  kick  by  a  horse — the  more  likelv  is  the  intestine  to  have  been 
injured.  Eigidity  of  the  abdominal  wall,  and  pain  and  tenderness  at 
one  spot,  are  the  most  reliable  symptoms.  Tympanites,  a  later  sign,* 
is  of  grave  omen,  as  it  greatly  embarrasses  operative  interference. 
Shockf  and  vomiting  afford  less  valuable  evidence,  unless  persistent. 
The  absence  of  each  has  led  to  fatal  delays.  A  certain  diagnosis  is 
seldom  possible  for  twelve  hours  or  longer,  but  the  surgeon  should 
not  wait  on  this  account.  The  risk  nowadays  of  doing  harm  by 
exploring,  in  cases  where  no  laceration  of  the  intestine  or  mesentery 
is  present,  is  much  less  than  that  of  waiting  to  explore  until  the  onset 
of  a  septic  peritonitis  affords  certain  evidence.  As  in  intestinal  obstruc- 
tion, abdominal  section  is  the  only  means  of  clearing  up  the  diagnosis. 

Mr.  Robson  (Clin.  Soc.  Trans.,  vol.  xxi.  p.  130)  advises  as  follows 
on  the  question  of  operation :  "In  cases  of  doubt  one  is  so  prone  to 
wait,  hoping  for  the  turn  of  events,  and  then  to  arrange  to  operate, 
when  too  late,  that  it  is  well  to  have  some  formulated  rule,  and  for 
my  own  guidance  I  have  adopted  the.  following.  In  cases  where 
there  is  a  reasonable  belief  that  the  intestine  is  wounded,  exploration 
by  a  small  median  incision  must  be  made,  when,  if  there  is  any  rupture 
of  the  bowel,  flatus,  or  serum  tinged  with  blood,  or  fseculent  material 
will  escape  through  the  small  peritongeal  opening,  which  can  be  enlarged 
and  necessary  treatment  adopted  ;  but  should  no  flatus  or  fluid  appear 
and  the  peritonaeum  prove  to  be  health}',  the  small  wound  can  be 
closed." 

That  the  best  chance  is  afforded  b}'  early  oi^eration  as  soon  as  the 
period  of  shock  has  passed  off,  is  proved  hy  recorded  results  (Battle). 
This  surgeon  points  out  (^loe.  infra  cit.)  that  in  the  second  paper  read 
before  the  Clinical  Societ}^  (Trans.,  1890)  by  Mr.  Croft,  out  of  four- 
teen cases  then  collected  only  one  was  completely  successful,  a  case 
operated  on  b}'  Mr.  Croft ;  and,  between  1 890  and  1 894,  Mr.  Battle 
had  collected  fifteen  cases,  seven  of  which  recovered. 

Treatm.ent. — Where  rupture  of  intestine  or  severe  haemorrhage  is 
probably  present,  exploration  should  take  place  as  soon  as  the  period 
of   shock  has    passed    away.      The    incision   should  be   median   and   a 

*  When  present  early  and  abolishing  the  liver  dulness  this  is  almost  pathognomonic 
of  injury  to  the  alimentary  canal. 

f  Shock  is  quite  unreliable,  as  it  depends  not  only  on  the  severity  of  the  injury  but 
on  the  idiosyncrasy  of  the  patient. 


RUPTUEE  OF  THE  INTESTINE.  293 

long  one,  at  least  fonr  inches,  the  parietes  here  being-  normal,  not 
distendecl  and  atrophied  as  in  abdominal  tumours.  When  all  the 
intestine  has  to  be  drawn  out  and  examined — and  no  operation 
can  be  otherwise  complete — the  incision  should  be  eight  inches 
long.  In  any  case  the  centre  should  be  at  the  umbilicus,  unless 
it  is  clear  that  it  is  the  stomach  that  is  injured.  It  should  not 
be  lower  down,  or  the  attacliment  of  the  mesentery  may  interfere 
with  the  pulling  out  of  the  intestine,  especially  if  it  be  short  and 
thickened  with  fat.  Blood  may  show  through  the  peritonseum  before 
this  is  opened.  When  this  membrane  is  incised  a  sponge  should  be 
passed  in  on  clamp-forceps  to  search  for  blood,  faeces,  or  pus.  If 
hemorrhage  is  going  on.  the  opening  the  abdomen  may  stop  it 
(Pai'kes.  Med.  News.  May  17,  1884),  or  it  may  increase,  causing  gi-ave 
symptoms.  If  blood  well  up,  a  hand  should  be  passed  in,  under  the 
omentum,  upwards  and  backwards,  to  make  pressure  on  the  abdominal 
aorta  and  root  of  the  mesentery.  All  the  small  intestine  is  then  turned 
out  into  hot  aseptic  towels ;  bleeding  points  are  found,  and  secured 
with  clamp-forceps  while  the  pressure  is  relaxed  to  note  the  effect  on 
the  bleeding.  The  bleeding  having  been  arrested,  any  injury  to  the 
intestine  is  sought  for.  If  a  I'lipture  is  found,  the  part  should  be  kept 
outside  in  a  hot  aseptic  towel,  while  the  rest  is  returned.  If  haemor- 
rhage is  slight  or  absent,  the  intestine  should  be  drawn  out  loop  by  loop, 
and  inspected  till  the  whole  is  examined.  Faecal  extravasation  should 
be  avoided  by  extremely  careful  handling  of  the  intestine,  the  wound 
thiis  remaining  unsoiled.  When  all  the  intestine  has  been  inspected,  the 
peritoneal  sac  should  be  carefully  cleansed  as  at  p.  215.  Any  dis- 
tended coil  may  be  aspirated,  and  the  puncture  tied  up  or  opened  as 
at  pp.  177,  214.  If  the  large  intestine  be  much  distended,  a  long 
rectal  tube  may  be  passed  and  manipulated  along  through  the  walls 
of  the  intestine.  Small  raptures  will  often  admit  of  suture  without 
resection.  Other  viscera  may  be  injured  and  have  to  be  dealt  with 
(vide  supra,  p.  285J.  When  the  case  is  too  grave  to  admit  of  resection 
being  performed  and  of  the  necessary  plastic  repair  taking  place,  the 
best  course  is  to  make  an  artificial  anus  by  closing  the  ends  of  the 
intestine  with  ligatures  or  clamps,  then  having  thoroughly  cleansed  the 
peritonaeal  sac,  next  bring  the  ends  out  and  insert  Paul's  tube  (pp. 
226.  258),  or  suture  the  ends  of  the  intestine  to  the  margins  of  the  cut 
parietal  peritoneum,  and  trust  to  the  presence  of  these  sutures  and 
plenty  of  iodoform,  to  hold  the  ends  of  the  emptied  intestine  in  place 
until  the  adhesions  are  firm.  This  course  ought  not  to  take  more 
than  half  an  hour.  Where  the  injury  is  high  up  in  the  intestine, 
additional  risk  must  be  run  in  order  to  avoid,  by  resection,  the 
artificial  anus  which  is  so  harmful  here.  If  the  anus  be  made  use 
of.  it  should  be  closed  as  early  as  possible,  or  the  nutrition  will 
suffer  fatally  (p.  276).  Saline  infusion  may  be  resorted  to  with  great 
advantage,  early  in  the  operation,  before  collapse,  perhaps  irrecovei-able, 
has  set  in.  No  operation  should  be  performed  if  marked  collapse  is 
present.  If  the  patient  does  not  respond  to  stimuli,  he  will  not  survive 
laparotomy. 

The  following  are   some    of  the    conditions  which    have    been    met 
with  in  exploration  of  injury  to  the  intestine. 


294  OPERATIONS  ON   THE  ABDOMEN. 

In  Dr.  AViggins'  case,  to  which  I  have  already  alluded,  thirty-six  hours  after  the 
boy  had  been  kicked  by  a  horse,  the  abdomen  was  opened  and  the  small  intestine 
withdrawn  and  carefully  examined,  beginning  with  the  ileo-CEecal  region.  Near  the 
jejunum  a  bruised  and  livid  knuckle  was  discovered.  Though  no  perforation  was  made 
out  in  it  prior  to  the  resection,  a  small  perforation  was  found  afterwards  near  the 
mesenteric  border.  About  six  inches  were  resected,  the  ends  being  united  by  Maunsell's 
method.  Owing  to  the  patient's  "  coming-to  "  and  straining  while  the  resection  was 
being  performed,  blood  and  fascal  matter  escaped  into  the  peritonaeal  sac,  this  accident 
being  due  to  the  safety-pins  used  as  clamps  being  too  large.  A  50  per  cent,  solution  of 
hydrogen-dioxide  was  poured  in,  and  allowed  to  remain  while  the  ends  were  being 
united,  and  the  cavity  was  afterwards  flushed  with,  and  finally  left  full  of,  sterilised 
salt  solution.  The  patient,  a  boy  aged  15,  made  a  good  recovery  (^Ncw  York  Med. 
Journ.,  Jan.  20,  1894). 

In  a  case  fully  reported  by  Mr.  Battle  {Lancet,  vol.  i.  1894,  p.  1121, 
a  paper  which  will  well  repay  perusal),  the  following  was  the  condition 
present  when  the  peritoneum  was  opened.* 

A  gush  of  blood  followed,  and,  as  the  patient  was  sti-aining,  a  coil  of  intestine  was 
forced  out.  A  rent  was  found  in  the  mesentery  of  this  coil,  bleeding  freely.  While  this 
hfemorrhage  was  being  arrested  with  clamp-foTceps,  the  open  end  of  a  piece  of 
intestine  sprang  into  the  wound.  The  other  end  was  found  by  tracing  the  mesentery 
along.  This  portion  of  mesentery  was  much  contused  and  lacerated,  and  there  was 
a  second  complete  rupture  about  eight  inches  from  the  first.  Only  a  small  portion  of 
the  contents  had  escaped,  among  which  were  one  or  two  partly  digested  beans.  As  it 
was  evident  that  the  condition  of  the  mesentery  would  result  in  gangrene  if  it  were 
left,  resection  was  performed,  nearly  thirteen  inches  being  removed  with  a  large  wedge- 
shaped  piece  of  mesentery.  While  a  lateral  anastomosis  was  being  performed  here  by 
Senn's  method,  it  was  discovered  that  a  third  rupture  existed  about  a  foot  beyond  the 
second.  This  rupture  was  not  quite  complete.  It  was  closed  "  by  means  of  Senn's 
plates,  cut  to  the  required  size,  and  a  ring  of  Lembert's  sutures  used  to  further 
strengthen  the  union."f  The  patient  did  well  until  the  fifth  day,  when  evidence  of 
perforative  peritonitis  appeared.  The  abdomen  was  again  opened,  and  it  was  found  that 
the  end-to-end  union  had  broken  down,  leading  to  leakage.  An  artificial  anus  was 
made,  but  the  patient  never  rallied. 

Mr.  Croft  has  recorded  two  cases  of  rupture  of  the  small  intestine 
without  external  wound  (Clin.  Soc.  Trans.,  vol.  xxi.  p  254,  and  vol. 
xxiii.  p.  141).  These  must  be  looked  upon  as  pioneering  cases,  as  far 
as  this  country  goes,  in  the  modern  treatment  of  these  injuries.  Both 
patients  recovered — the  one  completely,  after  primary  enterorraphy  by 
Lembert's  method ;  in  the  other  case  an  artificial  anus  was  made. 
This  was  closed  by  resection  of  the  intestines,  four  weeks  later,  but 
the  patient  sank,  thirteen  hours  after  the  operation,  from  exhaustion, 
due  chiefly  to  "the  irrepressible  escape  of  intestinal  contents  at  the 
artificial  anus."  The  following  points  amongst  many  others  are  note- 
worthy in  the  two  last  instructive  cases  : 

In  the  first  case,  three  separate  lesions  were  discovered  ;  the  ileum  had  been  ruptured 
transversely  for  two-thirds  of  its  circumference  at  the  junction  of  its  upper  and  middle 
thirds.  There  was  a  laceration  of  an  inch  and  a  half  in  the  mesentery  in  the  same 
neighbourhood,  and  a  considerable  rent  in  the  omentum  above  the  level  of  the 
umbilicus.     Fsecal  peritonitis  had  spread  from  the  ruptured  intestine  into  the  iliac 

*  The  patient,  aged  24,  had  been  kicked  in  the  abdomen  by  a  horse.  He  was 
admitted  into  St.  Thomas's  Hospital  shortly  after,  and  was  operated  upon  about  six 
hours  later  when  the  shock  had  passed  ofl^. 

t  This  operation  lasted  over  two  hours,  and,  owing  to  the  increased  shock,  five  pints 
of  saline  solution  were  injected  with  a  good  effect. 


RUPTURE  OF  THE  INTESTINE.  295 

umbilical,  and  hypogastric  regions,  eighteen  hours  and  a  half  having  elapsed  between 
the  injury  and  the  operation.  The  peritonaeum  was  very  carefully  irrigated  with 
warm  boracic  acid  solution  (from  16  to  20  per  cent.),  and  the  edges  of  the  ruptured 
intestine  brought  out  into  the  wound.  Mr.  Croft  points  out  that  the  result  of  this  case 
shows  that  it  would  pi'obably  have  been  a  safe  practice  to  have  trimmed  the  edges  of 
the  ruptured  gut  and  completed  an  enterorraphy  by  Lembert's  sutures,  as  the  irriga- 
tion was  evidently  efficient.  This  would  have  saved  the  inanition  and  debility  conse- 
quent on  the  establishment  of  an  artificial  anus,  the  external  irritation  and  the  septic 
condition  of  the  parts  around  the  opening,  and  the  second  long  and  risky  operation 
required  to  close  it. 

In  the  second  case,  fourteen  hours  had  elapsed  between  the  operation  and  the  kick 
from  a  horse.  A  faint  fsecal  odour  was  observed  when  the  periton£eal  sac  was  opened, 
and  about  an  ounce  and  a  half  of  faecal  fluid  was  found  extravasated  between  some 
coils  of  intestine  adherent  to  each  other  and  the  omentum.  On  tearing  through  the 
adhesions  and  separating  the  coils  on  the  right  side,  about  two  inches  below  the 
umbilicus,  a  small  rupture  was  found  in  the  ileum,  situated  in  an  areola  of  inflamed 
a,nd  ecchymosed  tissue.  Resection  of  the  damaged  intestine  was  performed,  the  ends 
being  united  by  about  forty  Lembert's  sutures.  The  peritonseal  sac  was  carefully 
purified  with  a  hot  20  per  cent,  solution  of  boracic  acid.  The  patient,  aged  14,  made 
an  uninterrupted  recovery. 

I  can  only  find  space  for  one  other  of  these  most  interesting  cases. 
It  is  recorded  b}'  Mr.  W.  T.  Thomas,  Assistant-Surgeon  to  the  Royal 
Infirmary  at  Liverpool  (Brit.  Med.  Journ.,  vol.  i.  1894,  p.  1355).  It 
presents  the  following  points  of  interest  : — 

(1)  The  slightness  of  the  injury.  The  patient,  aged  55,  had,  twenty-four  hours 
before  the  operation,  struck  her  abdomen  against  a  chair  which  she  was  carrying  before 
her,  and  whicfi  caught  against  a  doorpost.  (2)  The  absence  of  symptoms  in  a  case 
of  severe  septic  peritonitis,  only  distension  and  tenderness  being  present.  Whea 
the  abdomen  was  opened,  about  half  a  pint  of  putrid  serum,  with  large  yellowish 
flakes  of  puriform  lymph,  escaped.  The  intestines  were  all  distended,  and,  as  no 
collapsed  coils  could  be  found,  the  small  intestine  was  withdrawn.  After  two  feet  had 
been  examined,  a  perforation  was  found*  about  three-quarters  of  an  inch  long,  from  which 
oozed  fcecal  fluid.  This  was  closed  by  two  rows  of  continuous  Lembert's  sutures,  the 
mucous  membrane  being  carefully  tucked  in.  Thorough  irrigation  with  a  1  per  cent, 
solution  of  carbolic  acid  was  then  carried  out,  a  glass  tube  being  left  in.  The  patient 
made  a  good  recovery. 

*  The  site  of  the  rupture  was  not  given.  Nor  is  it  stated  whether  much  difficulty 
was  met  with  in  dealing  with  the  distended  intestines. 


CHAPTER   VII. 
OPERATIONS   ON   THE   STOMACH. 

GASTROSTOMY.  —  GASTROTOMY.  —  DIGITAL  DILATATION 
OF  PYLORUS.— PYLOROPLASTY.— EXCISION  OP  PYLO- 
RUS.—GASTRECTOMY.— G  ASTRO- JE  JUNO  STOMY.—DUO- 
DENOSTOMY    AND    JEJUNOSTOMY. 

GASTROSTOMY. 
Indications. 

I .  Certain  cases  of  cancerous  stricture.  This  also  inclixles  invasion 
of  the  oesophagus,  secondarily,  from  primar}'  cancer  of  the  mediastinal 
glands.  &c.  2.  Cancerous  disease  of  the  pharynx  ;  and.  in  a  few  cases, 
malignant  disease  of  the  tonsil  or  back  of  the  tongue  not  admitting  of 
operation. 

A  very  interesting  case  is  given  by  Mr.  Whitehead  {Brit.  Med.  Jouni..  .July  22,  1882). 
Here,  in  a  patient  aged  40,  excision  of  the  tongue  liad  to  be  follo\ved  by  tracheotomy 
and  gastrostomy,  owing  to  the  original  extent  of  the  disease.  At  the  last  report  the 
patient  was  alive,  four  months  after  the  gastrostomy,  five  after  the  removal  of  the 
to  igne.  Two  such  cases  are  given  by  Mr.  Stonham  {^Lancet.  Oct.  2,  1886).  One  patient 
survived  four  months ;  the  other,  one.  In  this  case  the  growth  was  so  extensive  as  to 
Diecessitate  tracheotomy  at  an  early  stage  of  the  gastrostomy.  Both  patients  experienced 
great  relief.  Tracheotomy  was  also  required  in  Mr.  King  Green's  case  QLanci-t.  Feb.  3, 
1883),  though  here  the  disease  was  either  in  the  pharynx  or  upper  part  of  the 
oesophagus.  I  think  that  in  such  cases,  also,  the  last  few  months  of  life  might  often 
be  rendered  much  more  comfortable  by  a  timely  gastrostomy. 

3.  Cicatricial  stricture,  whether  traumatic  or  syphilitic. 

The  first  of  these,  from  its  frequency',  requires  separate  notice. 

I.  Cancerous  Stricture.  —  Here  several  points  call  for  attention. 
Amongst  the  chief  are — the  question  of  the  treatment  of  oesophageal 
cancer  by  passage  of  tubes  or  gastrostomy ;  the  mortality  of  the  latter 
operation  ;  and  the  best  date  for  performing  it. 

Between  treatment  by  gastrostomy  and  that  by  tubes  no  fair  com- 
parison can  be  made,  because  the  former  operation  has,  in  sitch  a  large 
number  of  cases,  been  performed  under  most  unfavourable  conditions. 
]\Iuch  too  often  it  has  been  put  off  till  the  patient,  scarcely  able  to 
swallow  liquids,  is  just  kept  alive  by  enemata.  Such  patients,  worn  out 
by  the  miseries  of  slow  starvation,  often  with  secondary  disease  and 
lung  and  pleural  trouble,  are   not  in  a  condition  to  be  submitted  to 


GASTROSTO^IY.  297 

abfloiiiinal  section,  and  are  not  likely  to  respond  to  the  call  made  upon 
their  vitality  to  unite  two  serous  surfaces  firmly  together,  on  which 
depends  the  success  of  the  operation.  I  do  not  think  that  I  exaggerate 
if  I  say  that,  in  a  distinct  proportion  of  the  cases  in  which  the  surgeon 
is  asked  to  perform  gastrostomy,  the  hand  of  death  is  already  on  the 
patient,  and  something  next  door  to  the  decomposition  of  the  grave  has 
already  set  in,  owing  to  the  extension  of  the  disease. 

In  advising  gastrostomy,  each  case  must  he  decided  on  its  merits  : 
the  patients  here  are  not  only  adults,  but  well  on  in  life,  and,  when 
assured  that  the  end  is  certain,  the  surgeon  ma}^  in  most  cases,  having 
put  all  the  risks  before  the  patient,  leave  it  to  him  to  decide.  But 
I  think  that  if  the  patient,  having  previously  declined  it,  only  asks  for 
operation  when  it  is  clearly  too  late,  the  surgeon  should  be  firm  enough 
to  decline  to  operate  where,  on  every  ground,  his  interference  will  be 
iiopeless. 

The  following  points  help  in  a  detnsion  between  gastrostomy,  bougies, 
and  tubage :  i.  Food  taken. — As  long  as  pulp}^,  semi-solid,  or  a  pro- 
portion of  solid  food  is  taken,  the  occasional  passage  of  a  bougie  should  be 
persevered  with.  But  when  the  patient  is  becoming  restricted  to  liciuids. 
a  tube  should  be  introduced,  or  failing  this  a  gastrostomy  performed. 
AMien  the  patient  is  fed  by  enemata  onW.  and  merely  takes  ice  by  tht- 
mouth,  it  is  too  late  to  operate,  ii.  Amount  of  pain  felt  with  and  diffi- 
culty in  passing  bougies  or  tubes. — Any  sensation  of  a  rough,  raw 
surface,  any  blood  or  broken-down  tissue  on  the  bougie,  increased  ex- 
pectoration, dyspnoea,  paroxj^smal  cough  (this  may  occur  after  even  a 
teaspoonful  of  fluids),  fcetor  of  sputum  or  bougie,  make  it  evident  that  the 
passage  of  instruments  causes  advance  of  ulceration  and  sloughing :  when 
this  is  increasingly  accompanied  with  pain  and  evidence  of  laryngeal 
irritation,  gastrostomy  should  be  proposed,  iii.  Site  of  stricture. — The 
lower  down  this  is,  the  more  difficulty  will  there  usually  be  in  dealing 
with  it  by  dilatation,  and  the  nearer  are  important  parts,  iv.  Condition  of 
patient. — Here  the  rate  of  emaciation  must  be  watched — anything  like  loss 
of  one  to  two  pounds  a  week  is  very  ominous.  How  far  is  the  strength 
preserved  ?  how  far  does  the  patient  tend  to  give  up  his  life-habits  ? 
how  far  is  he  bed-ridden  ?  Where  the  pulse  is  thready,  the  extremities 
cold,  the  temperature  never  up  to  normal,  the  case  has  gone  too  far. 
v.  Condition  of  viscera. — Evidence  of  implication  of  trachea  or  bronchi, 
of  pleuritic  effusion,  and  of  broncho-pneumonia  must  be  sought  for.  If 
there  is  reason  to  believe  that  the  growth  has  extended  beyond  the 
oesophagus,  operation  should  usually  be  declined,  vi.  Rank  of  life. — 
A  patient  who  can  afford  all  the  luxuries  of  life,  and  who  can  have 
everything  done  to  palliate  his  condition,  is,  obviously,  in  a  very  different 
condition  to  one  in  a  humbler  position. 

I  would  thus  sum  up  this  cpiestion  of  gastrostomy  or  tubage  : — As 
long  as  a  patient  can  swallow  sufficient  food  by  this  means,  treatment 
by  tubes  and  bougies  is  far  preferable.  AMienever  they  can  be  intro- 
duced, the  tubes    ino-eniously    devised    bv    Mr.   Svmonds*    are    to    be 


*  Clin.  Soc.  Trans.,  vols,  xviii.  p.  155,  xxii.  p.  306;  Brit.  Med.  Jonrn.,  April  23,  1887. 
See  also  Dr.  Rodman's  two  cases.  Brit.  Med.  Joiirn..  May  25,  1889.  It  is  clear  from 
these  cases  that  patients  can  be  kept  alive  as  long  and  gain  weight  equally  by  tubage 
as  by  gastrostomy,  and  that  in  some  cases  even  a  malignant  stricture  can  be  dilated. 


2gS  OPERATIONS  ON  THE  ABDOMEN. 

preferred.  These  have  a  funnel-shaped  extremity  resting  on  the  upper 
end  of  the  stricture,  are  introduced  on  a  whalebone  guide,  and  are 
kept  in  situ  by  a  loop  of  silk  \\'hich  is  passed  round  the  ear.  They 
have  the  great  advantage  of  allowing  the  patient  to  swallow  his 
saliva  and  food,  and  thus  retain  the  pleasures  of  taste.  If  the  silk 
break,  great  trouble  may  accompany  the  removal  of  the  tube. 

If  a  larger  pattern  of  bougie  is  needed,  none  is  more  suitable  than  the 
flattened  bulbous  one,  ending  in  a  conical  point,  of  Mr.  Durham.* 

Any  surgeon  treating  cancerous  stricture  here  by  dilatation  must 
remember  that  treatment  of  cancer  in  this  way  is  contrar}^  to  what 
is  generall}^  practised,  and  is  only  justifiable  here  on  special  grounds — 
e.g.,  the  fatality  of  the  disease  and  the  risks  of  gastrostomy^ ;  that  these 
risks  have  been  enormously  increased  by  the  way  in  which  this  opera- 
tion has  been  deferred ;  that  in  these  cases  a  time  may  come  when 
tubes  can  no  longer  be  made  use  of ;  and  that  if  gastrostomy  has  been 
deferred  till  now  it  can  only  be  jjerformed  with  greatly  increased  risk. 
In  other  words,  the  patient  should  understand  that  if  he  shuns  the 
risks  of  an  early  operation,  he  renders  himself  liable  to  other  but  as 
serious  risks  by  deferring  it  till  an  hour  when  he  can  on]}^  ask  for  it, 
and  the  surgeon  only  attempt  it,  as  an  almost  utterly  forlorn  hope. 

I'he  question  of  which  gives  the  greatest  comfort  cannot  be  answered 
dogmatically.  But  no  one  who  has  seen  manj^  cases  of  gastrostomy, 
and  met  with  a  fair  proportion  of  success,  will  hesitate  to  prefer  the 
result  of  this,  if  performed  early,  with  its  gain  of  weight  and  freedom 
from  pain  and  irritation  during  the  few  months  which  in  any  case 
remain,  to  the  passage  of  tubes  necessarily  more  and  more  frequent  and 
difiicult  as  the  case  progresses,  with  the  not  infrequent  distress  and 
choking  when  they  are  introduced,  the  blockage  of  the  hollow  ones 
by  sputum  or  food,  and  the  needful  withdrawal  and  re-introduction, 
easily  effected,  no  doubt,  for  some  time,  but  ever  irritating  and  fretting 
the  growth. 

I  have  performed  gastrostomy  twelve  times,  in  each  case  for  cancer 
of  the  oesophagus  :  in  six  patients  the  operation  was  asked  for  too 
late ;  in  one,  my  seventh  case,  the  patient  died  from  an  accident,  lor 
which  I  am  responsible ;  the  other  five  recovered  well.  One,  a 
young  married  woman,  had  had  symptoms  six  months ;  she  was  in  the 
fourth  month  of  pregnancy  when  operated  on :  she  lived  in  comfort  for 
six  months,  and  died  of  extension  to  the  lung,  a  month  after  giving 
birth  to  a  child  at  the  full  time.  Another  patient  lived  between  three 
and  four  months,  and  would  have  survived  longer  if  it  had  not  been  for 
his  carelessness  as  to  exposure.  A  third  was  alive  and  progressing 
satisfactorily  when  last  heard  of  four  months  after  the  operation.  The 
fourth  is  still  alive,  four  months  after  his  operation.  The  fifth  made  a 
good  recovery,  but  I  lost  sight  of  the  case  nine  weeks  after  the  operation. 

On  the  other  hand,  the  passage  of  tubes,  where  there  is  considerable  narrowing,  clearly 
requires  some  force,  and  thus  needs  skilled  and  very  careful  hands.  Even  in  such 
hands,  fatal  mischief  has  been  inflicted.  Furthermore,  the  blocking  of  the  smaller 
tubes,  which  alone  wiU  pass  in  the  later  stages  through  tight  and  ulcerating  strictures, 
may  necessitate  frequent  changing,  irritation,  and  thus  hastened  sloughing  of  the 
growth.  The  close  contiguity  of  this  to  the  trachea,  pleurte,  &c.,  must  not  be 
forgotten. 

*  Si/sf,  of  Shtij.,  vol.  i.  p.  798.     The  bougies  are  made  by  Krohne  and  Hawkslcy. 


GASTROSTOMY. 


299 


Fig.  116. 


Operation  (Figs.  1 16-122). — Those  precautions  being  taken  against 
sliock,  such  as  warm  wraps,  hot-water  bed,  table,  or  bottles,  ether  is 
given  if  the  condition  of  the  lungs  admits  of  it,  and  if  it  is  quietly 
taken  without  troublesome,  heaving  breathing.  The  surgeon  will  usuall}- 
find  it  most  convenient  to  stand  on  the  right  side  and  to  have  his  patient 
drawn  over  to  this  side  of  the  table.  The  shoulders  should  be  somewhat 
raised  and  the  hips  slightl}^  flexed,  to  relax  as  much  as  possible  the 
tension  of  the  soft  parts,  which  often  fall  with  embarrassing  sharpness 
over  the  epigastric  angle  from  the  prominent  ribs  down  to  the  wasted, 
retracted  umbilical  region  (Fig.  116). 

Mr.  Howse  (Did.  Trad.  Surg.,  p.  590)  recommends  the  following 
incision  :  (i)  An  oblique  one,  about  two  inches  and  a  half  long,  parallel 
with  and  about  one  inch  below  the  lower  margin  of  the  left  costal 
cartilages.  This  incision  should  start  about  an  inch  and  a  half  from 
the  middle  line,  and  its  length  must  depend  on  the  varying  development 
of  the  rectus  muscle.  It  should  not  go  higher  than  the  above  point,  as 
it  will  not  leave  enough  free  skin  and  muscle  between  the  cartilages  and 
the  incision  to  fasten  the  sutures  to. 
This  first  incision  is  only  to  be  carried 
through  the  skin  and  fascia.  When 
made,  the  sheath  of  the  rectus  will  be 
seen  at  the  inner  end,  and  at  its  outer 
end  a  portion  of  the  linea  semilunaris 
and  of  the  external  oblique.  The  usual 
plan  of  continuing  the  operation  is  to 
have  the  muscles  and  fascia  of  the 
abdomen  incised  in  the  same  way  as 
the  superficial  parts.  Mr.  Howse  prefers 
to  continue  the  operation  as  follows : 
(2)  The  lips  of  the  wound  being  sepa- 
rated towards  the  inner  part  as  widely 
as  possible  by  retractors,  a  vertical 
incision  is  made  in  the  sheath  of  the 
rectus  a  little  distance  from  its  outer 
margin.  The  vertical  fibres  of  this  muscle  will  then  be  seen,  and  these 
should  be  separated,  not  cut,  with  a  steel  director,  and  the  posterior  part 
of  the  sheath  exposed.     This  may  then  be  incised  vertically. 

From  my  experience  of  twelve  cases  I  prefer,  as  simpler,  a  single 
vertical  incision  (Fig.  1 1 6)  beginning  opposite  to  the  end  of  the  eighth 
intercostal  space  and  passing  down  for  three  inches  over  the  rectus — 
i.e.,  about  two  inches  from  the  linea  alba.  The  fibi-es  of  the  rectus,  being- 
exposed,  are  torn  straight  through  with  a  steel  director,  and  tlie  posterior, 
somewhat  concave,  layer  of  its  sheath  exposed.  This  is  carefully  divided 
for  the  full  length  of  the  incision,  and  the  extra-periton^eal  fat  (if 
present)  and  the  peritonasum  picked  up  and  opened  together.  A  finger 
is  now  introduced  (Fig.  116)  to  feel  for  the  stomach. 

As  a  rule,  the  contracted  stomach  lies  high  up  under  the  left  lobe  of 
the  liver,  and  requires  to  be  hooked  downwards  and  forwards  into  the 
wound.  Not  infrequently  the  great  omentum  presents  first,  and  it  is 
easy,  b}"  seeking  too  low  down,  to  draw  up  the  colon.  In  case  of  diffi- 
culty the  best  plan  is  to  find  the  anterior  border  of  the  liver,  trace  up 
the  under  surface  to  the  portal  fissure,    and    thence  along   the  lesser 


Tlie  finger  searchiug  for  the  stomach, 
through  a  vertical  incision. 


300 


OPERATIONS  ON  THE  ABDOMEN. 


omentum  to  the  stomach.  This  is  told  by  its  thicker,  more  substantial 
leel,  and  pink-red  colour. 

The  stomach  being  drawn  up,  a  part  is  chosen  on  its  anterior  surface, 
free  from  vessels,  and  as  near  as  possible  to  the  cardiac  end. 

A  number  of  different  methods  of  completing  the  operation  have  been 
devised,  the  object  being  to  produce  a  valvular  opening  into  the  stomach 
and  thus  prevent  constant  leakage  and  its  attendant  troubles.  The 
methods  described  below  are  the  most  satisfactory,  and  each  of  them 
has  strong  supporters,  the  advantages  claimed  being  the  formation  of  a 
satisfactory-  valve  and  the  absence  of  leakage.  Dr.  Dennis  (Ann.  of 
Surq.,  Nov.  1899,  p.  633)  describes  a  very  satisfactory  result  in  a  case 

Fig.   117. 
/  \  Fig.  118. 


"Witzel's  method  of  gast^•ostomJ^  Lem- 
bert's  sutures  have  been  so  placed  in  the 
walls  of  the  stomach  as,  when  tightened, 
to  draw  two  folds  of  the  walls  of  the 
stomach  over  the  tube.     (Meyer.) 


Witzel's  method  of  f^astros- 
tomy.  Sutures  tied  and  the  tube 
embedded  in  the  walls  of  the 
stomach.     (Meyer.) 


of  cicatricial  stenosis  of  the  oesophagus,  operated  upon  b}"  Marwedel's 
method  two  j^ears  previously'.  The  man  could  remove  and  insert  the 
tube  without  any  trouble,  and  there  was  no  leakage  when  the  tube 
was  out. 

The  results  obtained  by  the  methods  of  Albert  and  Ssabanijews- 
Franck  are  ver}-  satisfactory,  these  methods  having,  moreover,  the  great 
advantage  of  being  extremely  simple  and  quickly  pei'formed. 

i.  Witzel'.s*  Method  (Figs.  117  and  118). — The  peritonEeum  is 
opened  either  by  the  incision  parallel  to  the  left  border  of  the  ribs, 
or,  as  I  prefer  (p.  299),  by  one  through  the  rectus  muscle.  The 
stomach  having  been  drawn  out,  a  very  small  opening  is  made  near 

*  Centr.f.  Chir.,  1891,  p.  601.  An  interesting  account  of  this  method,  from  which 
Figs.  117  and  118  are  taken,  is  given  by  Dr.  W,  Meyer  (^Ann.  of  Surg.,  vol.  i.  1893, 
p.  592).  Witzel  gives  two  successful  cases.  Dr.  Meyer  quotes  Mickulicz  as  having 
operated  five  times  successfully,  and  as  recommencling  Witzel's  method  as  the  best. 


GASTROSTOMY, 


?OI 


its  cardiac  end,  and  a  snugly-fitting  rubber  tube  introduced,  and  then 
buried  in  the  wall  of  the  stomach  for  about  two  inches  by  Lembert's 
sutures,  two  folds  of  the  stomach  wall  being  stitched  over  the  tube,  as 
seen  in  Figs.  117  and  118.  The  free  end  of  the  tube  is  then  brought 
out  of  the  wound,  while  the  area  around  it  is  stitched  carefully  to  the 
peritongeum  on  either  side  of  the  Avound  in  the  parietes.  Prof.  Keen 
(Ann.  of  Sun/.,  vol.  ii.  1893.  p.  639)  thus  managed  this  part  of  the 
operation  : — the  tube  having  been  sutured  into  the  stomach,  three 
sutm-es  were  inserted  into  the  walls  of  this  viscus,  but  not  tied  before  it 

'^.  Fic.   119. 


Albert's  method  of  gastrostoiuj-.  The  stomacli  is  dra\vn  npw  ards,  while  below  the 
peritouaeum  aud  deeper  lajer  of  the  sheath  of  the  rectus  have  beeu  stitched  to  it 
bj'  a  continuous  suture.     Eetractors  hold  the  fibres  of  the  rectus  apart.     (Kocher.) 

was  returned  within  the  abdomen,  the  needles  being  left  threaded.  As 
soon  as  the  stomach  was  replaced  these  needles  were  thrust  through  the 
abdominal  wall,  and  the  stomach  brought  up  to  the  margins  of  the 
opening.  The  edges  of  the  wound  having  been  sutured,  the  upper 
end  of  the  tube  may  be  closed  with  a  clip,  and  the  usual  dressings 
applied.  Feeding  by  the  stomach  is  begun  at  once.  Any  leakage  is 
prevented,  not  onh'  by  this  oblique  entrance  of  the  tube  into  the  stomach, 
laut,  as  shown  by  a  specimen  obtained  from  a  patient  of  Dr.  Meyer  (loc. 
supra  cit.),   hx  the   fact    that  Witzel's    ingenious    method  of  stitching 


302 


OPERATIONS  OX  THE  ABDOMEN. 


the  stomach  walls  over  the  tube  causes  a  short  artificial  cone  to  protrude 
obliquely  into  the  lumen  of  the  stomach.* 

ii.  Method  of  Albert  (Figs.  119  and  120). — The  peritonaeum  is 
opened  either  by  an  incision  parallel  with  the  costal  cartilages,  or  by 
one  just  within  the  linea  semilunaris  high  up.  The  stomach  having 
been  drawn  out,  a  long  conical  diverticulum  of  the  anterior  wall  of  the 
viscus  is  pulled  well  out  of  the  wound,  and  the  parietal  peritonaeum  and 

Fig.   120. 


Gastrostomy  by  Albert's  method,  completed.  Below  is  seeu  the  chief  wound 
closed  by  a  continuous  suture.  Above  is  the  small  opening  through  which  the 
stomach  has  been  opened.     (Kocher.) 

the  posterior  layer  of  the  sheath  of  the  rectus  are  sutured  round  its  base, 
care  being  taken  not  to  constrict  it  too  much  (Fig.  1 19).  A  continuous 
suture  is  used,  and  every  care  taken  not  to  perforate  the  mucous  coat  of 
the  stomach,  A  small  incision  is  now  made  through  the  skin  a  little 
above  the  front  and  on  the  level  of  the  costal  cartilages.  The  skin 
between  the  two  openings  having  been  separated  from  the  subjacent 
parts,  the  diverticulum  of  the  stomach  is  drawn  up  under  the  skin  and 


*  Another  advantage  of  Witzel's  method  is  illustrated  by  one  of  his  cases,  In  a 
patient  who  had  been  operated  upon  for  cicatricial  stricture  of  the  oesophagus,  the 
fistula  closed  spontaneously  within  sixteen  days  after  the  stricture  had.  been  dilated 
and  the  tube  removed  from  the  stomach  (Meyer). 


GASTROSTOMY.  303 

over  the  costal  cartilages  as  far  as  the  small  skin  incision,  to  the  edges 
of  which  its  apex  is  united  by  a  few  sutures.  A  small  opening  is  next 
made  here  into  the  stomach,  and  the  orifice  fixed  to  the  skin  by  one  or 
two  points  of  suture  (Fig.  120).  The  lower  part  of  the  wound  is  then 
closed  by  a  continuous  suture.  As  a  result  the  diverticulum  of  the 
stomach  is  drawn  upwards,  its  base  is  gripped  by  the  muscular  fibres  of 
the  rectus,  while  a  short  upward-directed  subcutaneous  oesophagus  is 
also  formed.  All  escape  of  fluid  is  thus  prevented  and  the  patient  can 
be  safely  fed  at  once. 

The  Ssabanijews-Franck  method  is  very  similar  to  the  above,  the 
upper  opening  being,  however,  here  made  one  inch  or  one  inch  and  a 
half  above  the  vertical  incision  and  not  over  the  costal  margin.  The 
valvular  aperture  so  formed  is  seemingly  as  efficient  as  in  Albert's 
operation,  although  the  length  of  the  canal  is  rather  less. 

iii.  Marwedel's  Method  (Figs.  121  and  122). — The  stomach  is 
exposed  and  attached  to  the  abdominal  incision  by  a  continuous  suture. 
The  serous  and  muscular  coats  are  then  incised  vertically  to  the  extent 
of  about  two  inches,  and  dissected  from  the  mucous  membrane  on  either 
side.     A  small  incision  is  then  made  through  the  mucosa  at  the  lower 

Fig.  121. 


Gastrostomy  by  Marwedel's  methocl  Gastrostomy  by  Marwedel's  metliodj 

First  stage.  Second  stage. 

end  of  the  incision,  and  a  rubber  tube  introduced  and  fixed  b}^  a  suture. 
The  tube  is  then  laid  verticall}^  along  the  mucous  membrane,  and  the 
incision  in  the  serous  and  muscular  coats  closed  over  it  as  shown 
in  Fig.   122.     An  oblique  valvular  aperture  is  thus  produced. 

iv.  Abbe's  Modification  of  Kader's  Method  (Ann.  of  Surg.,  Jan.  1899, 
p  113). — Here  a  circular  valve  is  formed  in  the  following  manner: — 
Through  the  abdominal  incision  a  conical  portion  of  the  wall  of  the 
stomach  is  withdrawn,  and  its  edges  sutured  to  the  parietal  peritoneum. 
Two,  or  even  three,  concentric  purse-string  sutures  are  then  passed 
circularly  round  the  protruding  cone.  A  small  incision  is  now  made  at 
the  apex  of  the  cone,  through  which  a  tube  is  passed.  The  nearest 
purse-string  suture  is  now  drawn  tight  round  the  tube,  and  the  latter 
then  pushed  inwards  till  the  next  suture  comes  into  contact  with  it, 
when  it  is  also  drawn  tight.  In  the  same  manner,  the  third  suture  is 
drawn  round  the  tube  after  further  inversion.  The  external  wound  is 
then  closed.  Feeding  through  the  tube  is  commenced  at  once.  After 
a  week  or  ten  days  the  tube  becomes  loosened,  and  is  then  only  passed 
at  meal-times.  The  inverted  cone  here  forms  a  circular  valve  which 
effectually  prevents  regurgitation.  This  was  so  in  each  of  six  cases 
described  by  Dr.  Abbe,  and  in  one  case,  in  which  death  +ook  place  from 


304  OPERATIONS  OX  THE  ABDOMEN. 

heemoiThage  from  the  growth  four  days  after  operation,  there  was  not 
the  slightest  leakage  when  the  valve  was  tested  b}-  hydraulic  pressure. 

For  the  first  few  davs  milk  and  brandy,  just  warmed,  and  peptonised 
if  preferred,  should  be  the  chief  food,  given  with  the  yolks  of  one  or  two 
eggs.  A  little  later  beef-tea.  soups,  well-pulped  vegetables,  with  plenty 
of  fluid,  should  be  given.  In  Mr.  Howse's  words.  •"When  the  larger 
sizes  of  tubes  have  been  introduced,  solid  food  may  be  ]30ured  into  the 
stomach  by  the  aid  of  a  large  wide-mouthed  sj-ringe.  This  food  should 
be  minced  meat,  ^^•ith  a  certain  proportion  of  vegetables,  all  finely 
ground  in  the  mincing  machine." 

Patients  are  often  very  ingenious  in  feeding  themselves.  Some,  to 
enjoy  the  taste  of  food,  have  masticated  solids  and  then  passed  them 
through  the  fistula.* 

If  the  operation  has  been  deferred  till  too  late,  and  it  is  absolutely 
needful  to  feed  the  patient  at  once,  the  best  method  will  probably  be 
either  Franck's  or  Kader's.  If  the  opening  is  deferred,  a  small  amount 
of  liquid  may  be  introduced  every  few  hours  through  one  of  the  large 
hypodermic  syringes  made  for  exploration,  and  holding  a  drachm  or 
two.  The  puncture  must  be  repeated  at  each  occasion  of  feeding, 
obviously  a  risk_v  proceeding. 

Dilatation  of  Strictures  of  the  CEsophagus  from  below  through 
an  Opening  in  the  Stomach. — Where  non-malignant  strictures  low 
down  in  the  oesophagus  resist  dilatation  from  above,  and  the  patient  is 
losing  ground,  the  stricture  may  be  attacked  from  below  in  one  of  the 
following  ways: — 

(i.)  By  Grastrotoniy,  the  opening  being  closed  at  the  same  time. 
Prof.  Loreta,  of  Bologna,  operated  on  the  first  case  in  1885.! 

The  patient,  aged  24,  had  swallowed  caustic  alkali.  Attempts  to  dilate  the  stricture 
by  bougies  were  unsuccessful,  and  at  last  it  became  impossible  to  pass  any  instrument. 
The  point  at  which  the  sound  was  arrested  seemed  to  correspond  with  the  fourth 
dorsal  vertebra.  The  patient  was  entirely  unable  to  swallow,  and  emaciation  had 
become  extreme.  Eleven  months  after  the  injury  an  incision  about  five  inches  long 
was  made  from  the  xiphoid  cartilage  downwards  and  to  the  left.  Some  difficulty  was  met 
with  in  finding  the  stomach,  owing  to  its  contraction  and  the  way  in  which  the  liver 
overlapped  it :  but  at  length  the  operator  succeeded  in  drawing  the  greater  part  of  the 
stomach  out  of  the  wound,  and  a  longitudinal  incision  was  made  through  its  walls  between 
the  two  curvatures,  having  its  upper  end  as  near  the  cardia  as  possible.  The  next  step 
was  to  find  the  orifice  of  the  oesophagus,  in  order  to  introduce  the  dilator ;  but  this  in- 
volved considerable  difficulty.^  and  the  search  was  interrupted  by  a  considerable 
quantity  of  bile,  which  regurgitated  from  the  duodenum  into  the  stomach.  At  length, 
by  searching  with  the  left  index  between  the  under  surface  of  the  liver  and  the  small 
curvature  of  the  stomach,  the  end  of  the  oesophagus  was  found.  Then  the  distended 
stomach  was  kept  drawn  down  by  an  assistant  while  the  operator  introduced  a  dilator 
(something  like  that  of  Dupuytren  for  lithotomy).  The  wound  was  then  sewn  up  and  the 
stomach  returned.  The  patient  rallied  well,  and  in  six  hours  swallowed  some  soup, 
with  the  yolk  of  an  egg.  to  his  great  joy,  as  for  twelve  months  he  had  been  unable  to  do 
more  than  swallow  mouthfuls.     Recovery  is  stated  to  have  been  complete. 

*  Thus.  Mr.  Durham  {Si/,st.  of  Surg.,  vol.  i.  p.  803  ;  Loud.  Mtd.  Rec,  March  1878) 
mentions  a  patient  of  Trendelenburg's  who,  after  masticating  his  food,  spat  it  into  a 
funnel,  and  then  forced  it  on  through  a  tube  into  his  stomach.  Two  of  my  later 
patients  have  fed  themselves  after  this  fashion  through  a  tube. 

t  An  excellent  summary  of  Prof.  Loreta's  cases  is  given  by  Mr.  Holmes  {Brit.  Med. 
Jonrn.,  Feb.  21,  1885). 

i  See  the  directions  given  at  p.  307. 


GASTROSTOMY.  305 

Mr.  Kendal  Franks  has  related  an  instructive  case  of  the  same  kind 
(Ann.  of  Surg.,  vol.  i.  1894,  p.  385  j  : — 

Here  the  whole  of  the  right  hand  was  introduced  into  the  abdomen,  and  the  index 
finger  into  the  stomach  through  an  opening  an  inch  long  situated  about  midway 
between  the  curvatures  and  the  orifices.  As  the  finger  could  only  just  reach  but  not 
dilate  the  stricture,  an  Otis's  dilating  urethrotome  (the  blade  having  been  removed) 
was  guided  by  the  finger  into  the  stricture,  screwed  up,  and  withdrawn  fully  expanded. 
After  this  had  been  done  both  laterally  and  antero-posteriorly,  an  oesophagus  bougie 
could  be  easily  passed  through  the  stricture  from  above.  The  wound  in  the  stomach 
was  united  with  two  continuous  sutures,  one  uniting  the  mucous  membrane,  the  other, 
by  Lembert's  method,  the  peritonjeal  coat.  The  patient  made  a  good  recovery.  Large- 
sized  bougies  could  be  passed  without  difficulty  or  pain. 

It  is  clear  that  the  above  method  may  be  resorted  to  with  great 
benefit  in  non-malignant  strictures,  low  down  in  the  oesophagus  where 
the  dilated  condition  above  the  contraction  makes  it  very  difficult  to 
hit  this  off  with  a  bougie. 

(ii.)  By  Gastrostomy. — This,  while  rendering  manipulations  safer  in 
a  measure,  cripples  the  surgeon's  movements,  as  it  will  be  impossible, 
however  much  the  fistula  be  dilated,  to  get  the  finger  passed  through 
it  anywhere  near  the  stricture  in  the  oesophagus. 

Instrumental  dilatation  can  alone  be  made  use  of  through  a  gastric 
fistula,  and  for  this  reason  the  method  by  two  stages  is  inferior  to 
the  other.  It  has  been  most  ingeniously  used  under  the  following 
circumstances : — 

In  1889,  Hagenbach  QCorrcspondcnzhlatt  Schiveizer  Aerzte,  No.  5)  directed  a  patient 
with  a  non-malignant  stricture  of  the  oesophagus  to  swallow  a  small  shot  attached  to  a 
long  thread.  This  was  drawn  out  of  the  stomach  through  the  fistula,  and  a  strong  silk 
thread  fastened  to  it  and  drawn  up  through  the  mouth.  To  the  lower  end  a  bougie 
was  tied,  and  increasing  sizes  were  daily  drawn  through  the  fistula. 

Dr.  R.  Abbe,  of  Newport  (Ann.  of  Surg.,  vol.  i.  1893,  p.  489),  advises 
what  he  calls  the  "  string"  method  in  the  treatment  of  dense  fibrous 
strictures.  A  gastrostomy  having  been  previously  performed,*  a  small 
gum-elastic  bougie  is  guided  through  the  stricture  from  below  up  into 
the  mouth,  and  a  stout  silk  ligature  passed  in  the  same  way.  This 
silk  being  see-sawed  backwards  and  forwards,  the  stricture  is  felt  to 
yield,  and  larger  bougies  can  then  be  passed. 

Difficulties  in  and  after  Gastrostomy. 

i.  The  very  prominent  angle  formed  between  the  ribs  and  the  sunken 
umbilical  region  (p.  299).  ii.  Haemorrhage.  This  will  be  almost  nil 
if  the  rectus  fibres  are  separated  with  a  dii'ector,  and  the  veins  on  the 
stomach  carefully  avoided,  iii.  Finding  the  stomach,  iv.  Drawing 
this  up  into  the  wound  if  itself  affected  by  disease,  as  when  the  primary 
disease  is  situated  very  low  down  in  the  oesophagus,  or  if  it  is  adherent 
hj  reason  of  secondary  deposits,  v.  Jerking  breathing  due  to  the 
anaesthetic,  vi.  Completing  the  second  stage  of  the  operation,  vii. 
Intense  pain  on  introducing  food  into  the  stomach. 

In  a  patient  of  Mr.  Butlin's  QBrit.  Med.  Joiirn.,  April  14,  1883)  this  was  found  to  be 
the  case,  the  patient  dying  nearly  a  month  after  the  operation.  Mr.  Butlin  attributes 
this  pain  to  his  opening  having  been  close  to  the  pylorus. 

*  In  this  and  the  preceding  instance  the  gastrostomy  opening  should  be  placed  as 
high  up  as  possible.  In  his  case  Dr.  Abbe  opened  the  oesophagus  near  the  root  of  the 
neck  as  well  as  performing  a  gastrostomy. 

VOL.  II.  20 


3o6  OPERATIO^■S  OX  THE  ABDOMEN. 

If  it  is  thought  that  the  opening  is  made  too  near  either  extremity 
of  the  stomach,  it  would  be  well  after  feeding  to  keep  the  patient 
turned  on  to  the  opposite  side.  viii.  Leakage  of  gastric  juice  and 
regurgitation  of  food.  This  is  an  extremely  troublesome  complication, 
leading,  as  it  does,  to  most  rebellious  dermatitis. 

Causes  of  Death  after  Gastrostomy. 

I.  Inanition  and  exhaustion,  the  operation  being  performed  too  late. 
2.  Peritonitis.  3.  Extension  of  the  disease  to  surrounding  pai'ts — e.g., 
trachea,  bronchi,  etc.  4.  Lung  affections — e.g.,  pneumonia  due  in  part 
to  the  operation^viz.,  the  anesthetic  and  enforced  recumbency,  and 
in  part  possibly  to  the  saliva,  which  cannot  pass  down  the  oesophagus, 
being  dra^n  into  the  air-passages,  either  before  or  during  the  ope- 
ration. 5.  Haemorrhage — e.g.,  from  ulceration  into  aorta  or  lung. 
6.  Acute  gastritis.  7.  Suppuration  between  stomach  and  liver,  and 
due  probably  to  irritation  round  one  of  the  sutures. 


GASTROTOMY. 

Indications. — The  operation  may  be  required  for  the  removal  of 
foreign  bodies  which  will  not  pass  through  the  pylorus,  such,  for 
instance,  as  forks,  as  in  MM.  Labbe's  and  Peau's  cases,  and  masses  of 
hair  as  in  Thornton's  (Lancet,  Jan.  9,  1886)  patient.  Increasing  pain, 
vomiting,  emaciation,  and  sufficient  time  having  elapsed  to  allow  of  the 
body  passing,  will  be  the  chief  indications.  In  a  very  few  cases 
o-astrotomy  will  be  recpired  also  for  the  removal  of  foreign  bodies 
impacted  low  down  in  the  oesophagus.  It  is  also  indicated  in  certain 
cases  of  severe  gastric  haemorrhage,  and  for  the  dilatation  of  fibrous 
strictures  of  the  oesophagus  (vide  supra,  p.  304). 

Operation. — A.  For  Removal  of  Foreign  Bodies  from  the 
Stomach. — Such  cases  as  Mr.  Thornton's  show  that  this  operation 
can  be  safely  performed  at  one  stage. 

The  parts  being  cleansed  and  the  abdomen  relaxed,  one  of  the  follow- 
ing incisions  is  made: — (i)  Over  the  body  itself,  when  this  can  be 
felt.  (2)  In  the  case  of  a  large  body,  in  the  middle  line,  fj'om  the 
xiphoid  cartilage  down  to  or  below  the  umbilicus.  (3)  One  of  the 
incisions  given  for  gastrostomy — e.g.,  one  parallel  with  the  left  costal 
margin  and  about  an  inch  below  it,  reaching  from  a  point  near  the 
xiphoid  cartilage  obliquely  downwards  and  outwards  to  a  point  opposite 
to  the  ninth  rib.  One  of  the  first  two  will  probably  be  the  best.  The 
abdominal  wall  having  been  divided,  and  the  peritonasum  opened,  the 
exact  site  of  the  foreign  body  is  made  out.  If  this  be  pointed,  great 
care  must  be  taken  not  to  let  it  damage  the  stomach  during  the  needful 
manipulations.  In  such  cayes  the  external  opening  must  be  free,  that 
the  surgeon  may  see  what  he  is  about.  In  the  case  of  such  a  body  as 
a  fork  the  blunt  end  must  first  be  found. 

When  the  surgeon  has  decided  where  to  open  the  stomach,  he  brings 
this  part  out  of  the  wound  and  packs  sterile  gauze  all  around  it,  so  as 
to  steady  it,  and  also  to  shut  off  the  peritonaeal  sac. 

The  stomach  is  now  opened  with  scissors  by  an  incision  transverse 
to  its  long  axis,  and  of  length  adapted  to  the  case.  As  far  as  possible, 
any  vessels  must  be  avoided,  but  any  that  bleed  will  at  once  be  com- 


GASTPtOTOMY.  307 

mandecl  by  Spencer  Wells's  forceps.  The  body  is  next  extracted  Avitli 
suitable  forceps  or  a  scoop,  care  being  now  taken  not  to  damage  the 
stomach,  especially  if  the  foreign  body  has  set  up  inflammation  or 
ulceration,  and  to  allow  no  blood  or  mucus  to  escape  into  the 
peritonieal  sac. 

After  the  i-emoval  of  the  foreign  body,  if  the  stomach  contains  miich 
mucus  or  blood,  this  may  be  removed  by  gentle  sponging.  The 
aperture  in  the  stomach  is  then  closed  with  Lembert's  or  Halsted"s 
sutures,  and  the  wound  sutured. 

B.  FoK  Removal  of  Bodies — e.j/..  Tooth-plates — impacted  in  the 
Lower  Part  of  the  (Esophagus. — These  cases,  though  rare,  are  so 
difficult  as  to  call  for  some  remarks  here.  Prof.  Richardson,  of  Harvard 
University,  first  brought  forward  a  very  successful  case  of  this  opei'ation 
(Lancet,  1 887.  vol.  ii.  p.  707).  A  i:»late  carrving  four  teeth  had  been 
impacted  eleven  months  in  a  patient  aged  thirtj—seven.  Numerous 
attempts  had  been  made  to  remove  it  from  the  mouth.  The  plate  was 
successfully  I'emoved  by  gastrotomy,  by  an  incision  six  inches  long 
parallel  to  the  lower  margin  of  the  left  ribs.  The  following  intei'esting 
details  are  given  : — 

Determination  of  the  Site  of  the  Forevju  Bod;/. — In  an  individual  of 
average  height,  and  with  a  neck  of  ordinary  length,  the  distance  from 
the  incisors  to  the  diaphragm  is  fourteen  and  a  half  inches.  All  parts 
of  the  oesophagus  are  accessible  to  the  finger  either  by  gastrotomy  or 
external  oesophagotomy.  With  the  right  forefinger  introduced  by 
oesophagotomy  and  the  left  by  gastrotom}^,  it  was  found  possible, 
not  only  to  make  the  fingers  touch,  but  in  many  cases  overlap. 
But  these  results  are  onh'  approximate,  as  it  would  not  always 
be  possible  to  do  both  operations  on  a  patient.  It  is  possible 
to  reach  A\ith  the  left  hand  three  inches  above  the  cardiac  open- 
ing— i.e.,  the  length  of  the  left  middle  finger.  From  above, 
through  the  wound  in  the  neck,  one  cannot  reach  quite  so  far  on 
account  of  the  sternum  and  clavicle.  Allowing  in  the  average  neck 
one  and  a  half  to  two  inches  from  the  cricoid  cartilage  to  the 
lowest  point  of  the  wound  in  the  oesophagus,  we  have  the  average 
distance  from  that  incision  to  the  cardiac  opening  of  five  and  a  half  or 
six  inches.  If  the  obstruction  be  less  than  six  inches  from  the  cricoid, 
an  attempt  should  be  made  to  remove  it  from  above ;  if  more  than  this, 
or  thirteen  inches  from  the  teeth,  gastrotomy  should  be  performed. 
The  incision  that,  on  the  whole,  is  recommended  is  an  oblic[ue  one 
below  the  margin  of  the  left  ribs.  The  stomach  being  drawn  up  into 
the  wound,  it  is  most  essential  to  put  the  lesser  curvature  on  the  stretch, 
so  that  it  makes  a  straight  line  to  the  diaphragmatic  opening.  The 
cut  through  the  stomach  wall  must  be  far  enough  to  the  right  to  allow 
the  passage  of  instruments  along  the  sulcus  between  the  anterior  and 
posterior  walls  of  the  stomach,  made  tense  as  above.  If  the  instrument 
is  brought  obliquely  to  this  groove  and  passed  upwards,  all  the  time 
being  pressed  gently  against  the  straightened  lesser  curvature,  it  will 
glide  into  the  oesophagus  every  time  with  the  greatest  ease.  The  open- 
ing in  the  stomach  should  be  fii'st  large  enough  to  admit  instruments  ; 
if  these  fail,  it  must  be  enlarged,  and  the  whole  hand  introduced. 

In  the  following  case  I  was  much  less  fortunate,  owing  to  the  way 
in  which  the  tooth-plate  was  jammed  above  the  cardiac  orifice.     While 


3o8  OPERATIONS  ON  THE  ABDOMEN. 

such  cases  are  rare,  they  are  most  important,  on  account  of  the  numer- 
ous difficulties  which  the}'  present. 

E.  W..  aged  44,  was  sent  to  me  at  Guy's  in  May,  1S89,  having  swallowed  a  vulcanite 
tooth-plate,  which  '•  stuck  in  his  throat."  The  plate  originally  carried  seven,  but  now 
only  two  teeth.  A  medical  man  whom  he  saw  at  once  pushed  the  plate  down  with  a 
bougie.  An  emetic  which  had  been  given  then  acted  and  brought  up  some  blood.  The 
patient  complained  of  constant  pain  in  the  epigastric  region,  just  below  the  xiphoid 
cartilage,  and  in  his  dorsal  vertebrje.  Swallowing  was  painful,  and  so  was  eructation  of 
gas,  though  this  gave  relief.  Patient  was  able  to  swallow  food  quite  well.  He  was 
not  troubled  by  vomiting.  A  bougie  could  be  passed  into  the  stomach,  but  just  before 
it  entered  it  rubbed  over  a  foreign  body.  The  body  did  not  yield  in  the  least  to  any 
force  which  I  thought  it  justifiable  to  use  with  the  bougie.  On  June  11,  I  operated  as 
follows :  The  stomach  having  been  washed  out  with  dilute  boracic  acid,  an  incision 
three  inches  and  a  half  long  was  made,  parallel  with  the  linea  alba,  commencing  on 
the  level  of  the  xiphoid,  and  about  an  inch  to  the  left  of  it.  The  rectus,  the  sheath, 
being  opened,  was  split  with  a  steel  director.  The  stomach  was  very  small  and 
pale.  Sponges  having  been  packed  around,  it  was  opened,  with  scissors,  just  to 
the  right  of  the  cardiac  end,  and  as  high  up  as  possible.  The  opening  was  about  a 
quarter  of  an  inch  long.  Three  small  vessels  sprang,  and  were  tied.  The  exploring 
finger  detected  the  body  imbedded  just  above  the  cardiac  orifice.  The  mucous 
membrane  around  felt  pidpy  and  swollen.  Numerous  curved  forceps  were  introduced 
by  the  opening,  and  then  along  the  lesser  curvature,  but,  though  the  body  was 
repeatedly  seized,  I  was  quite  unable  even  to  loosen  it.  This  was  due  to  its  not 
presenting  any  projecting  points  and  to  the  swelling  of  the  mucous  membrane  around. 
I  next  enlarged  the  opening  in  the  stomach  so  as  to  introduce  my  hand,  but,  though 
with  the  tip  of  the  middle  finger  I  was  able  to  reach  the  plate,  I  was  unable  to  dislodge 
it.  Mr.  Durham  and  Mr.  Davies-CoUey  also  tried,  with  a  like  result.  Moreover,  to 
steady  it,  Mr.  Tubby  was  good  enough  to  keep  the  end  of  an  oesophageal  bougie  pressed 
against  it  from  above.  I  closed  the  lower  two-thirds  of  the  wound  in  the  stomach  with 
Lembert's  sutures  of  fine  silk,  and  stitched  the  remaining  part  to  the  upper  part  of 
the  parietal  incision,  so  that  other  forceps  might  be  tried  later  on.  The  patient,  how- 
ever, never  rallied  completely,  and  sank  about  forty-eight  hours  afterwards.  At  the 
post-mortem  examination  the  coronary  arteries  were  found  in  an  advanced  stage  of 
atheroma.  There  was  no  peritonitis  or  escape  of  gastric  contents.  The  mucous 
membrane  near  the  cardiac  orifice  of  the  stomach  presented  a  ragged  appearance 
dating  to  the  prolonged  manipulations.  The  plate  was  very  firmly  fixed  in  the  oeso- 
phagus, one  inch  and  a  half  above  the  cardiac  opening. 

C.  For  certain  Cases  of  Severe  Hemorrhage  from  a  Gastric 
Ulcer. — A  considerable  number  of  these  cases  have  been  operated  on, 
with  a  fair  measure  of  success,  although  at  the  present  time  the  exact 
indications  for  operation  and  the  best  methods  of  dealing  with  the 
ulcer  cannot  be  said  to  be  finally  settled. 

The  following  are  a  few  of  the  cases  that  have  been  reported;  they 
give  some  idea  of  the  various  means  that  have  been  adopted : — ■ 

Roux  {Revue  de  Gynccologie,  1897,  p.  113)  reported  two  successful  cases.  In  the  first 
he  ligatured  the  bleeding  vessel  and  then  excised  the  ulcer ;  and  in  the  second  he  ■ 
ligatured  the  artery  at  the  two  ends  of  the  lesser  curvature  without  removal  of  the 
ulcer.  Guniard  {Thv^;  Trognon,  Paris,  1893)  performed  gastro-enterostomy  for  a  bleed- 
ing pyloric  ulcer,  with  recovery.  Kuster  {Aim.  of  Stirtj.,  Aug.  1894)  cauterised  the 
ulcers  in  two  cases,  and  in  each  also  performed  gastro-enterostomy,  with  recovery.. 
Korte  QProceedinr/s  of  the  German  Surrjical  Congress,  1897)  cauterised  an  ulcer  which 
could  not  be  extirpated,  the  patient  dying  eight  days  later,  a  perforation  of  the- 
splenic  artery  being  found  at  the  necropsy.  Mickulicz  {These  dc  Marlon,  Paris,  1897). 
reported  two  cases.  In  the  first  he  excised  the  ulcer,  and  the  patient  recovered;  in 
the  second  he  used  the  cautery,  the  patient  dying  the  same  evening.  Cazin  {Prcsse 
Medicale.  1899.  p.  31)  reports  a  case  in  which  he  found  four  erosions.     These  were- 


GASTltUTOMV.  309 

sutured  with  catgut,  and  the  patient  recovered  without  further  ha3iuorrhage.  In  a 
number  of  cases  the  operation  failed  owing  to  inability  to  discover  the  ulcer.  Finally, 
in  an  exhaustive  paper  by  Drs.  Andrews  and  Eisendrath  (^A?m.  of  Surf]..  Oct.  1899)^ 
from  which  the  greater  part  of  the  following  is  gathered,  two  brilliantly  successful 
cases  operated  upon  by  Dr.  Andrews  are  described,  the  plan  adopted  here  being  liga- 
tion of  the  idcer  en  masse  within  the  cavity  of  the  stomach. 

The  ulcers  which  give  rise  to  serious  haemorrhage  are  usually  situated 
on  the  posterior  wall  of  the  stomach,  and  nearer  to  the  lesser  curvature 
than  the  greater.  The  character  of  the  ulcers  is  very  variable.  They 
may  be  small  and  quite  superficial,  when  the  bleeding  commonly  arises 
from  vessels  in  the  submucous  layer  ;  or  they  may  be  deep  and  adherent 
to  structures  outside  the  stomach,  leading  to  ulceration  of  large  vessels, 
such  as  the  aorta,  or  the  hepatic,  coronary,  splenic,  or  pancreatico- 
duodenal arteries.  It  should  also  be  borne  in  mind  that  in  a  number 
of  cases  more  than  one  ulcer  or  erosion  was  present.  Leube  and 
Kocher  give  as  indications  for  operation  recurrent  severe  haemorrhages 
when  careful  dieting,  rest,  and  other  medical  measures  have  failed. 
A  single  profuse  bleeding  is  not  necessarily  an  indication  for  operation, 
because  a  second  hasmorrhage  may  never  occur. 

Operation. — The  incision  must  be  free,  and  should  in  the  first 
instance  be  median.  If  this  does  not  give  sufficient  room,  the  left 
rectus  may  be  subsequently  divided.  The  chief  difficulty  is  the  find- 
ing of  the  ulcer.  The  anterior  surface  and  the  two  curvatures  of 
the  stomach  should  be  first  sj^stematically  examined  for  any  indurated 
spot ;  then  the  posterior  surface  is  reached  and  examined  by  passing  the 
hand  through  a  hole  in  the  great  omentum.  If  no  external  guide  to 
the  position  of  the  ulcer  is  found  in  this  waj^,  Andrews  and  Eisendrath 
recommend  the  examination  of  the  interior  of  the  stomach  through  a 
vertical  incision  in  the  anterior  wall,  this  incision  being  so  placed  as  to 
avoid  as  far  as  possible  any  large  vessels  which  are  visible.  Before  this 
incision  is  made,  the  stomach  must  be  withdrawn  from  the  abdomen 
as  far  as  possible,  and  carefully  isolated  with  sterile  gauze.  The  whole 
interior  of  the  stomach  is  then  carefully  and  systematically  inspected, 
a  strong  electric  light  being  essential.  Andrews  and  Eisendrath  carry 
this  out  in  the  following  manner — "The  hand  is  passed  behind  the 
organ  through  the  opening  in  the  omentum  already  mentioned.  The 
posterior  wall  is  now  pushed  forward  into  the  opening  and  passed 
portion  by  portion  into  plain  view.  This  may  be  continued  until  the 
whole  posterior  wall  to  the  cardiac  end  has  been  gone  over.  The 
greater  and  lesser  curvatures  and  the  remainder  of  the  anterior  wall 
may  in  the  same  manner  be  caused  to  invert  and  pass  in  review 
beneath  the  opening,  the  latter  being  caused  by  traction  to  assume 
various  positions  to  assist  in  this  invagination.  Should  the  posterior 
wall  be  adherent  to  the  pancreas,  as  in  Case  I.  and  somewhat  immovable, 
that  particular  part  of  the  viscus  should  be  inspected  by  reflected 
light.  In  such  a  case  the  lesser  peritonaeum  should  be  opened,  which 
will  give  additional  access  to  the  posterior  wall.  We  now  come  to  a 
portion  of  the  stomach  interior  which  cannot  be  drawn  down  or  forward 
— namely,  the  cardiac  end,  where  it  is  covered  by  the  left  lobe  of  the 
liver  and  attached  to  the  diaphragm.  To  inspect  these  parts  it  is 
necessary  to  illuminate  the  cavity,  and  retract  the  liver  and  costal  arch. 
The  Trendelenberg  position   would  probably  be  of   assistance  at  this 


3IO  OPERATIONS  OX  THE  ABDOMEX. 

stage,  both  in  gaining  access  and  in  the  matter  of  illumination.  With 
care  a  good  view  can  he  obtained  of  the  Avhole  cardiac  end  and  open- 
ing." The  treatment  of  the  ulcer  when  found  must  vary  according  to 
the  conditions  present.  If  the  ulcer  is  quite  small  and  superficial  it 
ma}'  be  cauterised.  In  all  other  cases  it  should,  if  possible,  be  excised. 
Excision,  however,  will  not  be  possible  when  the  base  of  the  ulcer  is 
adherent  to  parts  outside  the  stomach,  and  when  it  is  situated  at  the 
pjdorus.  In  the  former  case  it  may,  if  possible,  be  ligatured  en  masse, 
as  AndreAvs  (loc.  supra  cit.)  did  in  his  two  successful  cases  ;  failing 
this,  gastro-enterostomy  must  be  performed.  In  the  latter  case,  also, 
recourse  should  be  had  to  gastro-enterostomy  (vide  p.  327). 


DIGITAL    DILATATION    OF    THE     ORIFICES     OF    THE 

STOMACH. 

We  owe  this  operation  to  Prof.  Loreta,*  of  Bologna,  whose  two 
first  cases  Mr.  Holmes  was,  I  believe,  the  first  to  bring  prominentl}- 
under  the  notice  of  English  surgeons. 

It  has  since  been  almost  entirelv  replaced  by  the  operation  of 
pyloroplasty  (p.  312):  but  in  a  few  cases  of  benign  stricture  of  the 
pylorus,  unsuitable  for  pyloroplasty,  it  will  still  be  useful ;  for  instance, 
where  the  pylorus  is  embedded  in  adhesions,  or  is  very  rigid. 

Operation. — The  stomach  should  be  \\q\\  washed  out  a  few  days 
before,  and  also  on  the  morning  of  the  operation,  with  dilute  solutions 
of  boracic  or  salicylic  acids,-f-  and  the  time  fixed  should  be  as  early  as 
possible  in  the  day.  The  previous  meals  should  be  fluids,  small 
in  amount  and  readily  digested.  The  skin  being  cleansed,  an 
anaesthetic  given,  and  the  parts  relaxed,  an  incision  about  five  inches 
long  is  made  either  in  the  linea  alba  or  on  the  right  side  of  the  middle 
line,  from  a  point  about  one  inch  below  and  outside  the  xiphoid  cartilage 
to  one  just  below  the  cartilage  of  the  ninth  rib.  Haemorrhage  having 
been  arrested,  the  peritonasum  is  opened,  and  one  or  two  fingers 
introduced  to  feel  for  and  examine  the  pylorus.  No  definite  tumour 
will  probably  be  felt,  but  distinct  hardness  of  the  pylorus.  If  the 
omentum  is  adherent  to  the  stomach,  it  must  be  separated  after  both 
this  and  the  pylorus  are  drawn  out  of  the  wound.  Gauze  is  now 
most  carefully  packed  around  the  pjdorus,  and  the  stomach  is  opened 
with  blunt  scissors,  about  the  centre  of  its  anterior  aspect,  but  rather 
nearer  to  its  pvloric  end.  Any  bleeding  points  having  been  secured  by 
Spencer  Wells's  forceps,  the  right  index  examines  the  condition  of  the 
pyloric  orifice.     While  attempts  are  made  to  dilate  it,  this  part  of  the 

*  Prof.  Loreta's  first  case  is  reported  in  the  Lancet,  Aug.  18, 1883.  The  ninth  opera- 
tion, one  of  dilatation  of  the  cardiac  orifice,  is  briefly  given  in  the  same  journal  April 
26,  1884.  Mr.  Holmes'  summary,  a  very  full  one,  of  two  papers  by  Prof.  Loreta,  will  be 
found  in  the  Brit.  Med.  Jmtrn.,  Feb.  21,  1885.  Any  surgeon  about  to  perform  these 
operations  should  refer  to  this.  Mr.  Haggard's  case — the  first  successful  one  per- 
formed by  an  English  surgeon — was  published  in  the  Brit.  Med.  Journ.,  Feb.  19,  1887. 
In  the  same  journal  for  March  17,  1888,  is  a  note  that  the  patient  continues  perfectly 
well. 

t  In  one  case,  that  of  Mr.  Pearce  Gould's  (p.  312),  the  use  of  this  even  was  followed 
by  temporary  ill  effects.  As  long  as  the  washing  out  is  thoroughly  done,  boiled  water 
used  tepid  will  be  quite  eflScieut. 


DILATATION  OF  THE  PYLORUS.  31I 

stomach  is  steadied  by  the  k^ft  hand.  Much  gentleness  and  patience 
must  be  used  in  applying  the  great  force  which  is  often  required  for 
dilatation.  Mr.  Haggard,  finding  that  he  could  not  introduce  his 
finger,  used  a  pair  of  dressing-forceps,  and.  having  thus  started  the 
dilatation,  followed  it  up  by  the  passage  of  a  female  urethra  dilator 
(probably  having  guarded  the  blades  with  drainage-tube),  and  dilated 
gradually  till  he  was  able  to  get  his  "  index  and  next  finger  into  the 
duodenum  without  feeling  them  at  all  tightly  packed."  Prof.  Loreta, 
in  his  first  case,  having  introduced  his  right  index,  found  that  "  no 
force  that  could  be  safely  used  succeeded  in  dilating  it  till  the  left 
index  was  also  introduced  and  employed  to  steady  the  pylorus.  When 
this  was  done,  the  end  of  the  right  forefinger  was  gradually  squeezed 
through  the  aperture.  Then  the  finger  was  used  to  hook  down  the 
pylorus  towards  the  abdominal  wound,  a  manoeuvre  which  enabled  the 
operator  to  get  the  left  index  also  through  the  pjdorus.  But  it  was 
still  exceedingly  difficult  to  effect  any  separation  of  one  finger  from  the 
other,  so  great  was  the  resistance,  not  only  of  the  sphincter  itself,  but 
also  of  the  coats  of  the  stomach  and  duodenum.  The  attempt  at 
dilatation  threw  the  muscular  fibres  into  spasmodic  action,  which  quite 
overcame  all  the  force  that  could  be  exerted.  Three  such  attempts 
were  made  in  vain,  but  then  the  pvlorus  began  slowly  to  yield  to  the 
force  emploj^ed,  which  was  very  considerable.  At  length  a  sensation 
was  experienced,  '  showing  that  the  tissue  was  so  far  distended  that 
it  could  not  obey  the  dilating  finger  further  without  being  torn.'  The 
fingers  were  now  kept  apart  for  a  short  time,  and  the  spectators  noted 
that  one  finger  was  about  eight  centimetres  (more  than  three  inches) 
from  the  other."* 

The  wound  in  the  stomach  is  next  closed  with  Lembert's  suture  of 
carbolised  silk  ;  or  the  method  emploj-ed  hj  Mr,  Thornton  (p.  306)  may 
be  made  use  of.  The  sutures  should  pass  through  any  points  that  still 
bleed  after  forci-pressure  is  stopped.  If  any  ligatures  are  really  required, 
fine  chromic  gut  should  be  used.  Perhaps  the  introduction  of  a  sponge 
during  the  insertion  of  the  sutures  may  facilitate  this  step  b}"  everting 
the  mucous  membrane.  When  the  stomach  is  soundly  closed,  all 
gauze  is  removed  from  the  peritonasal  sac,t  the  viscus  replaced,  and 
the  wound  in  the  abdomen  carefully  closed.  It  should  be  noted  that  in 
Mr.  Haggard's  case  ''terrific  bleeding  followed  the  incision"  into  the 
stomach,  and  Avas  difficult  to  arrest  completel}'  during  the  suturing  of 
the  stomach.  Pure  blood  was  vomited  on  the  third  day,  and  about  two 
teaspoonfuls  on  the  sixth.  As  Sir  F.  Treves  points  out  (loc.  infra  cit.), 
if  care  is  taken  to  make  the  opening  in  the  stomach  only  large  enough 
to  admit  the  index  finger,  it  will  be  securely  plugged. 

The  after-treatment  will  consist  in  rectal  feeding  for  the  first  few 
days,  feeding  by  the  mouth  then  being  cautiously  commenced.  Prof. 
Loreta  feeds  his  cases  by  the  mouth  very  earh',  if  needful — ''  on 
the  fourth  day  "  (Haggard) ;  according  to  his  own  paper,  on  the  same 
evening,  in  his  first  case,  he  gave,  every  half-hour,  teaspoonfuls  of  the 


*  However  the  dilatation  is  effected,  it  should  be  kept  up  for  several  minutes. 

t  If  any  cleansing  of  the  peritoiueuni  is  required,  this  will  be  done  now.  To  prevent 
any  chance  of  leakage,  sutures  should  be  placed  at  the  very  angles  of  the  wound,  or 
even  beyond  them  (Fig.  55). 


312  OPERATIONS  ON  THE  ABDOMEN. 

yolk  of  an  egg  beaten  up  with  Marsala.  The  condition  of  the  patient, 
and  the  way  in  which  enemata  are  retained,  must  decide  this  point.  If 
the  suturing  be  efficient,  a  little  milk  and  barley-water  with  a  few 
drops  of  brandy  may  be  given  six  hours  after  the  operation. 


PYLOROPLASTY. 

This  is  a  scientific  advance  on  Prof.  Loreta's  operation  for  the  relief 
of  non-malignant  strictures  of  the  pylorus,  e._(/.,  those  due  to  congenital 
stenosis,  corrosive  poisoning,  injury,  cicatrised  ulcers,  and  chronic  gas- 
tritis. We  owe  the  operation  to  Heineke  and  Mickulicz,  who  performed 
it  independently  in  1886  and  1887. 

In  pyloroplast}'  a  definite  plastic  operation  re^^laces  a  divu.lsion  per- 
formed more  or  less  in  the  dark.  The  two  operations  are  very  well 
contrasted  by  Mr.  Pearce  Gould  in  an  instructive  paper  (Lancet,  1893, 
vol.  i.  p.  1 183): — "  Of  the  two  methods  of  obtaining  a  wider  pylorus, 
pyloroplasty  was  chosen  as  safer  and  more  likely  to  be  permanently 
successful  than  Loreta's  operation  of  divulsion.  Both  operations  entail 
incision  into  the  stomach  and  subsequent  suture  of  the  wound  ;  so  far 
their  perils  are  the  same.  But  whilst  pyloroplasty  consists  of  a  clean 
cut  through  the  anterior  wall  of  the  p^'lorus.  where  it  is  most  free  from 
large  vessels  and  under  the  operator's  eye,  the  eflects  of  divulsion  are 
not  seen  and  may  be  more  or  less  than  the  surgeon  intends,  and  may 
be  inflicted  upon  important  vessels.  The  statistics  of  Loreta's  operation 
show  cases  of  death  from  complete  rupture  of  the  j)ylorus  on  its  posterior 
aspect,  and  also  from  hsemorrhage ;  the  plastic  operation  is  entireh^  free 
from  these  dangers.*  A  further  most  important  consideration  is  the 
cjuestion  of  relapse.  Divulsion  has  been  followed  by  recurrence  of  the 
stricture,  and  in  many  cases  the  operation  has  been  repeated ;  and, 
looking  to  analogous  cases,  this  is  what  one  would  expect.  A  sudden 
dilatation  of  the  strictured  urethra  or  rectum  is  well  known  to  be 
followed  by  relapse  unless  sjDecial  means  are  used  to  maintain  the 
enlargement.  All  such  special  means  are  inapplicable  in  the  case  of 
the  stomach.  Stretching  the  pylorus  may  consist  of  over-stretching 
the  muscular  ring,  analogous  to  stretching  the  sphincter  ani.  This  may 
be  entirely  satisfactory  in  its  result ;  on  the  other  hand,  it  may  eiFect  a 
tearing  and  stretching  of  fibroid  or  cicatricial  tissue — a  process  known 
to  be  very  unsatisfactory  in  many  cases.  Pyloroplast}^,  on  the  other 
hand,  introduces  new  and  presumably  healthy  tissues  into  the  pyloric 
ring,  tissues  with  no  tendency  to  contract.  In  this  connection  it  is 
interesting  to  remember  the  results  obtained  by  the  free  division  of  the 
palmar  fascia  in  Dupuytren's  contraction.  Not  only  is  the  shortened 
fascia  lengthened,  but  the  indurated  tissue  softens  down  and  all  signs 
of  the  malady  may  disappear." 

Operation  (Figs.  1 23  and  1 24). — The  preliminarj-  treatment  as  to  diet, 
and  washing  out  the  stomach,  is  that  given  at  p.  310.     The  abdomen 

*  Mr.  P.  Swain,  of  Plymouth,  whose  operative  experience  is  well  known,  has 
candidly  published  QLancet,  1892,  vol.  i.  p.  87)  two  cases  of  digital  dilatation  of  the 
pylorus  which  ended  fatally.  Both  patients  were  in  very  weak  condition ;  one 
died  of  continued  vomiting.  In  the  other,  the  duodenum,  which  was  very  thin, 
was  torn  quite  through,  behind,  at  its  junction  with  the  pylorus. 


Pl'LOROPLASTY. 


31 


having  been  opened  by  a  free  incision  either  in  the  linea  alba  or  semi- 
hmaris,  and  all  haemorrhage  stopped,  the  pylorus  is  found,  brought  out 
of  the  wound  if  possible,  and  in  any  case  well  packed  around  with  tam- 
pons of  iodoform  or  sterile  gauze.  Adhesions  between  the  pylorus  and 
omentum,  or  between  the  pylorus  and  the  liver,  may  need  separating. 
A  transverse  incision  is  then  made  into  the  anterior  wall  of  the  stomach, 
just  internal  to  the  pylorus,  by  which  the  stricture  is  examined  from 

Fig.  123. 


Pj-loroplasty.  first  stage,  showing  the  longitudinal  incision.     (Pearce  Gould.) 

Fig.  124 


Pyloroplasty,  second  stage,  showing  the  longitudinal  wound  converted  into  a 
transverse  by  retraction.     (Pearce  Gould.) 

within.  The  incision  is  next  prolonged  transversely  through  the 
strictured  pylorus  into  the  duodenum,  making  it  about  two  inches 
long.  Any  vessels  which  spirt  must  be  clamped.  Any  contents  of 
the  stomach  which  may  escape  are  carefully  removed  on  gauze.  The 
transverse  incision  is  then  widely  opened  out  by  two  blunt  hooks, 
placed  in  the  centre  of  each  side  ;  this  produces  a  wound  of  lozenge 
shape,  which  is  united  so  as  to  form  a  vertical  one.  Any  soiled  sponges 
or  tampons  being  renewed,  the  sutures  are  inserted  in'  a  double  row. 


314  OPERATIONS  OX  THE  ABDOMEN. 

There  are  several  ways  of  doing  this.  A  continuous  suture  uniting  the 
mucous  membrane  and  a  row  of  Lembert's  sutures  (Fig.  55)  carried 
well  into  the  muscular  coats  would  be  simple  and  efficient.  Fine  silk 
should  be  used  on  ordinary  round  sewing-needles.  To  strengthen  the 
line  of  suture  any  tags  of  peritonjeal  adhesions  which  have  been 
separated  and  left  attached  near  the  incision  may  be  brought  together 
and  fixed  over  it  by  a  few  points  of  suture.  The  after-treatment  will 
be  that  given  at  p.  311. 

Successful  cases  will  be  found  recorded  hj  Mr.  Page,  of  Newcastle 
(Lancet,  1892,  vol.  ii.  p.  84);  Mr.  Gould,  loc.  supra  cit. :  Mr.  Morison 
{Lancet,  1895,  vol.  i.  p.  396).  Mr.  Gould  quotes  several  foreign 
operators,  and,  having  collected  twenty-three  cases,  finds  the  mortality 
to  be  about  25  per  cent.  Mr.  M.  Kobson  (B^-it.  Med.  Joiirn.,  1900. 
vol.  i.  p.  627)  makes  use  of  his  decalcified  bone  bobbin  (p.  241).  This, 
besides  steadying  the  line  of  sutures  for  twenty-four  or  forty-eight 
hours,  secures  an  immediately  and  thoroughly  patent  channel.  The 
same  author  (loc.  supra  cit.)  also  remarks  as  follows  on  the  limitations 
of  this  operation: — "If,  owing  to  cicatrisation  of  the  ulcer,  there  is 
extensive  hypertrophy  of  the  pylorus  with  a  large  amount  of  thickening, 
pyloroplasty  is  insufficient,  as  in  such  cases  contraction  will  be  likely 
to  recur.  Here  pylorectomy  may  be  performed,'  as  in  two  cases  of  my 
own,  or,  better  still,  gastro-enterostomy,  which  is  a  simpler,  quicker, 
and  safer  operation.  Numerous  and  firm  adhesions,  active  ulceration, 
and  the  presence  of  new  growth,  are  also  contra-indications  for 
pyloroplasty.  Pyloroplasty  with  partial  excision  seems  the  right 
practice  in  bad  organic  sti-icture.  The  dense  tissue  being  cut  awaj". 
the  lozenge-shaped  incision  can  be  readily  sutured  so  as  to  become 
transverse ;  whilst  if  a  simple  longitudinal  incision  is  made  through 
the  tissues  of  a  dense  stricture,  it  is  impossible  to  convert  it  safely 
into  a  transverse  line  of  sutured  wound,  owing  to  the  great  tension 
if  the  two  ends  be  made  to  meet  in  the  middle." 


PYLORECTOMY.       EXCISION    OF    THE    PYLORUS. 

This  operation,  which  we  owe  especially  to  German  surgeons — e.f/.. 
Billroth.  Wolfler,  Gussenbauer,  and  v.  Winiwarter — has  not  hitherto 
been  so  largely  practised  in  England  as  elsewhere.  The  principal 
indication  is  malignant  disease,  although  the  ojDeration  has  occasionally 
been  performed  for  non-malignant  stenosis  of  the  pylorus  (vide  sujjra). 
The  original  method  of  end-to-end  direct  suture  has  been  largely 
replaced  by  the  more  expeditious  methods,  in  which  the  divided  ends  of 
the  stomach  and  duodenum  are  closed  by  suture,  and  a  gastro-duodenos- 
tomy  or  gastro-enterostomj^  then  performed.  On  several  occasions  also 
the  operation  has  been  performed  in  two  stages — the  gastro-enterostomy 
being  first  performed  ;  then,  after  the  general  condition  of  the  patient 
has  improved  as  a  i-esult  of  the  relief  from  pyloric  stenosis,  the  removal 
of  the  pylorus  is  carried  out.  This  has  been  done  by  Tupolske,  Hahn. 
Franke.  Barker,  and  others.  ^Ir.  Mayo  Robson  (loc.  supra  cit.,  p.  696) 
objects,  however,  to  this  plan,  on  the  ground  that  the  patient  may 
derive   so    much    benefit    from    the   first  operation  that   he  cannot  be 


PYL0EECT03IY.     EXCISIOX  OF  THE  PYLORUS.  315 

alwaj's  brought  to  see  the  necessity  of  a  second  operation  until  it  is 
too  late  to  be  successful. 

The  improvements  in  technique  have  led  to  a  considerable  diminution 
in  the  mortality,  as  may  be  gathered  by  a  comparison  of  the  following- 
sets  of  cases  collected  in  1885  and  1900: — 

Mr.  Butlin  quotes  Bramer  (Cent.  f.  Chir..  1 885,  p.  548)  as  having 
collected  sevent3'-two  cases  of  pylorectomy  for  cancer,  of  which  fifty- 
five  died  from  the  operation,  a  mortalit}-  of  y6  per  cent. 

Mr.  Mayo  Robson  (loc.  supra  cit.)  gives  a  table  containing  572  cases, 
with  174  deaths,  a  mortality  of  30'4  per  cent.  Some  operators  have, 
moreover,  published  recent  lists  showing  far  better  results  than  even 
this.  For  instance,  Maydl  had  onlv  four  deaths  in  twenty-five  cases, 
and  Kocher  onl}^  five  deaths  in  fifty-seven  cases. 

As  regards  the  question  of  pylorectomy  compared  with  gastro-enter- 
ostomy  onl}^  the  following  words  of  Dr.  Macdonald's  (Ann.  of  Surg., 
Feb.,  1901,  p.  160),  referring  to  the  results  of  pylorectom}',  may  be 
quoted  : — "  I  have  taken  occasion  recently  to  make  a  cursory  investiga- 
tion of  the  literature  with  relation  to  this  subject,  and  have  been  able 
to  find  fortj'-three  cases  for  which  p3"lorectomy  was  done  for  carcinoma 
of  the  stomacli,  and  that  the  patients  were  living  without  recurrence 
three  years  after  the  operation,  and  that  there  were  patients  in  this 
group  Avho  were  alive  ten  3'ears  after  the  primary  operation,  without 
symptoms  of  recurrence.  I  may  also  say  that  this  group  of  forty-three 
cases  is  collected  from  among  527  operations  done  for  the  relief  of 
pyloric  carcinoma,  with  an  immediate  mortality  of  31  per  cent.  In 
other  words,  we  have  from  the  work  already  done  rather  more  than 
8  per  cent,  of  final  recoveries  as  judged  by  ordinary  standards.  This 
will  compare  very  favourably  with  the  ultimate  success  Avhicli  Ave 
enjoA'ed  a  few  years  ago  in  the  treatment  of  cancer  of  the  breast." 

Before  deciding  between  a  pylorectomy,  on  the  one  hand,  and  a 
gastro-jejunostoni}^  oj^ly?  ^^^  ^^^  other,  the  followiDg  conditions  must 
be  most  carefully  considered : 

i.  The  size,  fixity,  and  degree  of  displacement  of  the  pyloric  growth. 
Is  the  mass  small,  circumscribed,  and  localised  to  the  i)ylorus? — i.e., 
how  far  is  it  (a)  without  any  secondary  deposits  ?  (jB)  free  from 
adhesions  ?  It  is  probabl}^  quite  impossible  to  be  certain  as  to  these 
points.  While  in  many  cases  cancer  of  the  pylorus  may  remain  long 
limited  to  the  pylorus  itself,  it  is  very  liable  to  infect  the  omenta  and 
the  Ijmiphatic  glands  around  the  head  of  the  pancreas,  and  to  cause 
secondary  growths  in  the  liver  and  other  parts.*  Adhesions,  too,  are 
very  frequentlj^t  met  with  between  the  stomach  and  the  colon,  pancreas. 
and  liver.  Tlie  following  cases  show  how  easily  the  surgeon  may  be 
mistaken  in  regard  to  these  points.  In  Mr.  Southam's  patient  (Brit. 
Med.  Journ.,  July  29,  1882 — an  instructive  paper,  from  which  I  shall 
again  quote  later),  aged  43,  though  the  hard  nodular  mass  in  the  situa- 

*  McArdle  (^Dublin  Journ.  Mtd.  Sci..  veil.  Ixxxiii.  p.  511).  having  collectecl  from 
the  statistics  of  difforenl  writers  1342  cases,  states  that  the  pyhu-iis  alone  was  in- 
volved in  802,  or  over  half  the  cases. 

t  The  statistics  of  Gussenbatier  and  Winiwarter  (Langenbeck's  Arcfi..  Bd.  xix. 
p.  372,  1876)  show  that,  of  542  cases  of  cancer  of  the  pylortis,  adhesions  were 
present  in  370. 


3l6  OPEEATIOXS  ON  THE  ABDOMEN. 

tion  of  the  pylorus  moved  with  respiration,  and  shifted  as  the  patient 
moved  from  side  to  side,  though  the  symptoms  were  only  of  four  months' 
duration,  and  the  disease  appeared  to  be  limited  to  the  pylorus,  there 
was  a  mass  of  enlarged  glands  surrounding  the  head  of  the  pancreas, 
and  some  slight  adhesions  of  the  stomach  to  these.  Mr.  Morris  men- 
tions a  patient  of  Prof.  Lietherin's  in  whom,  though  the  growth  could 
be  easily  moved  in  different  directions,  it  was  found  so  firmly  adherent 
that  the  operation  had  to  be  abandoned. 

ii.  The  strength  and  age  of  the  patient.  The  general  condition, 
power  of  repair.  &c.,  must  be  sufficient  to  justify  the  patient  being 
submitted  to  an  operation  on  very  vital  parts,  which  will  certainly  take 
an  hour  and  a  half,  and  may  take  between  two  and  three  hours. 

iii.  The  rate  at  which  vomiting,  pain,  and  emaciation  are  increasing. 
Where  tliis  is  marked,  pylorectonn^  should  be  abandoned. 

iv.  The  amount  of  dilatation  of  the  stomach,  and  how  far  this  yields 
to  washing  out. 

Where  the  surgeon  remains  in  doubt  as  to  the  advisability  of 
pylorectomy  up  to  the  time  that  the  abdomen  is  opened,  the  presence 
of  extensive  adhesions  between  the  stomach  and  adjacent  parts,  liver, 
pancreas,  &c.,  the  existence  of  secondary  deposits  or  enlarged  glands, 
the  extension  of  the  disease  into  the  omenta — if  an}^  of  these  are 
present — pylorectomy  should  be  abandoned. 

If  pylorectomy  be  decided  upon,  one  of  the  following  methods  may 
be  adopted : 

i.  Kocher's  Method.  ii.  Pylorectomy  combined  with  Gastro- 
duodenostomy  or  Gastro-enterostomy.  iii.  Pylorectomy,  with  direct 
suture  of  the  divided  ends.  iv.  Pylorectomy,  the  ends  being  directly 
united  by  some  such  means  as  Robson's  bobbin. 

For  some  daj's  before  the  operation  the  stomach  should  he  washed 
out  with  tepid  water,  syphon-fashion,  by  an  india-rubber  tube  and  fun- 
nel, till  the  contents  come  out  clear,  this  being  done  more  frecjuently 
according  to  the  degree  of  dilatation  of  the  viscus.  Immediately 
before  the  operation*  the  stomach  is  again  washed  out  with  some 
dilute  aseptic  solution,  as  ^^•ell-diluted  salicylic  acid,  or  boro-glyceride 
(l  in  30),  or  potassium  permanganate.  For  some  time  beforehand  the 
patient  must  be  fed  with  that  food  which  is  found  to  cause  least 
vomiting.  In  Mr.  Southam's  case  this  was  found  to  be  peptonised 
milk  and  ciistard.  The  bowels  should  be  well  cleared  out  with  enemata, 
and  every  precaution  at  the  time  of  the  operation  should  be  taken 
against  shock — viz.,  wrapping  up  the  patient  well,  a  hot-water  bed,  hot 
bottles,  bandaging  the  limbs  in  flannel,  keeping  the  head  low,  the 
administration  of  ether  if  possible,  or  A.C.E.,  for  the  greater  part  of 
the  operation,  and  subcutaneous  injections  of  ether  and  brandy. 

(i.)  Kocher's  method  of  combined  Pylorectomy  and  Gastro- 
duodenostomy. — The  following  account  is  taken  from  Koclier  (Opp/r. 
Surg.,  trans,  by  Stiles,  1 895,  p.  134).  A  central  incision,  four  to  six 
inches  long,  is  carried  downwards  below  the  umbilicus  for  a  distance 
corresponding  to  the  position  of  the  tumour.     The  umbilicus  is  excised 

*  In  Mr.  Southam's  case  the  need  of  this  final  washing  was  proved  by  the  fact  that 
a  quantity  of  dark-coloured  grumous  matter  was  brought  away,  which  otherwise  might 
have  escaped  into  the  peritonasal  sac. 


PYLORECTOMY  AND  GASTIIO-DUOUENDSTOMY. 


317 


and  all  hfiemorrhage  arrested.  The  tumour  is  next  drawn  out  as  far  as 
possible,  and  its  limits  carefully  determined.  The  omenta  are  separated 
above  and  below  over  an  area  corresponding  to  the  amount  to  be 
removed.  This  separation  should  run  as  close  to  the  stomach  as  is 
consistent  with  complete  removal  of  the  disease,  and  is  effected  by 
the  finger  or  a  blunt  instrument,  all  bleeding  points  lieing  ligatured. 

Fig.   125. 


Line  of  separ- 
ation of  lesser 
omentum. 


Cancerous 
portion. 

Line  of  separ- 
ation of  great 
omentum. 


Eesection  of  the  pylorus,  first  stage.  The  carcinomatous  portion  is  isolated  by 
separatmg  the  omenta,  and  then  shutting  it  off  by  means  of  clamps.  The  cavity 
of  the  stomach  is  shut  off  by  the  fingers  of  an  assistant,  and  that  of  the  duodenum 
by  clamps.      The  hues  of  section  are  indicated  by  interrupted  lines.     (Kocher.) 

After  isolating  the  tumour,  sterilised  gauze  is  passed  beneath  it  and 
around  the  duodenum  and  stomach,  so  as  to  prevent  their  contents 
reaching-  the  interior  of  the  abdomen.  A  clamp  is  now  placed  upon 
the  duodenum  close  to  the  edge  of  the  tumour,  and  two  (these  beino- 
in  line,  one  from  above  and  the  other  from  below)  upon  the  stomach, 
well  to  the  gastric  side  of  the  tumour  {vide  Fig.   125).      The  clamps 


i8 


OPERATIONS  ON  THE  AIJDOMEN. 


are  large  arterj^  forceps,  closed  by  the  usual  catch.  They  may  be 
closed  without  hesitation,  as  there  is  no  danger  of"  causing  necrosis  of 
the  gastric  or  intestinal  walls.  A  second  clamp  is  placed  upon  the 
healthy  duodenum,  parallel  to  and  beyond  the  first,  and  the  intestine 
is  then  cut  across  between  them.  The  edge  of  the  gut  which  projects 
beyond  the  clamp  is  thoroughly  disinfected  by  means  of  a  small  swab 
soaked  in  a  l  in  lOOO  sublimate  solution.  The  divided  duodenum 
toA^'ards  the  side  of  the  growth  is  merely  wrapped  round  with  sterilised 

Fig.   126. 


stomach 
dosed  by  a 
continuous 
huture  which 
penetrates  all 
the  coats. 

Mucous  mem- 
brane of 
stomach. 


Eesectiou  uf  the  pylorus,  .second  stage.     (Koclier.) 

i^'auze  and  lifted  out  with  the  growth  ;  the  other  end  of  the  duodenum 
is  folded  over  the  right  margin  of  the  wound  and  covered  provisionally 
with  moist  gauze.  The  assistant  now  grasps  the  stomach  from  above 
and  below  between  the  forefinger  and  thumb,  or  between  the  index  and 
middle  fingers  of  each  liand,  in  order  to  close  it  securely  ;  and  after 
placing  a  ring  of  gauze  over  the  hands  of  the  assistant  and  round  the 
stomach,  the  surgeon  cuts  across  the  latter  well  to  the  cardiac  side  of 
the  two  clamps.  The  new  growth  is  laid  aside,  and,  after  any  escaped 
gastric  contents  have  been  swabbed  up,  and  the  more  imj)ortant  bleeding 


rVT.OIJECTOMV   AMI   rjASTKO-DUODENOSKBIY. 


319 


vessels  secured,  tlie  stomach  is  closed  by  a  continuous  silk  suture  which 
penetrates  all  three  coats  {vide  Fig.  126).  The  projecting  edges  of  the 
mucous  membrane  are  thoroughly  cleansed  with  sublimate  solution. 
The  continuous  deep  suture  is  then  invaginated,  and  a  continuous 
Lembert's  suture  carefully  aiDplied,  so  as  to  keep  the  serous  coats 
reliably  and    completely  approximated    in    their   whole   extent.      Any 

Fig.  1:27. 


PoPt-sorous 
suture 
betwpin 
stomach  aiul 
duodenum. 

Duodenum... 


.■Assistant's 
thumb  closing 
stomacli  and 
duodenum  by 
pressure. 


Resection  of  the  pylorus,  third  stage.     (Kocher.) 

gauze  which  is  soiled  having  been  changed,  the  assistant  grasps  the 
stomach  so  as  to  direct  its  posterior  wall  forM'ard  and  to  the  right. 
The  posterior  wall  of  the  duodenum  (with  the  forceps  still  clamping  it) 
is  now  applied  to  the  posterior  wall  of  the  stomach  in  such  a  \vay 
that  a  continuous  posterior  seroxis  suture  may  be  comfortably  introduced 
between  it  and  the  stomach  from  the  upper  to  the  lower  edge  of  the 


320  OPERATIONS  ON  THE  ABDOMEN. 

intestine  (ride  Fig.  127).  It  is  only  now  that  the  forceps  are  removed 
from  the  duodenum.  The  escaping  contents  are  thoroughly-  removed 
and  the  lumen  disinfected.  Ligatures  are  applied  to  any  bleeding- 
points.  The  stomach  is  next  incised  about  a  quarter  of  an  inch  from 
the  posterior  serous  suture  for  a  distance  corresponding  to  the  opening 
in  the  duodenum.*  Another  continuous  -posterior  suture  is  next  intro- 
duced, this  one  taking  up  all  three  coats.  The  ends  of  the  posterior 
sutures,  which  have  been  left  long,  are  now  re-threaded  and  employed 
in  succession  for  the  anterior  sutures,  the  oi^der  being  reversed.  The 
protecting  gauze  having  been  removed,  the  lines  of  suture  are  again 
thoroughly  disinfected,  the  stomach  and  intestine  replaced,  and  the 
wound  closed.  Instead  of  uniting  the  cut  end  of  the  duodenum  into 
an  opening  in  the  stomach,  the  surgeon,  after  a  free  pylorectomy, 
might  close  the  end  of  the  duodenum  as  well  as  that  of  the  stomach, 
and  then  unite  the  viscera  by  Halsted's  or  some  other  method 
(p.  269). 

Kocher  emphasises  the  following  points  as  essential  to  success  : 
(i)  The  operation  must  be  performed  aseptically,  and  the  greatest  care 
must  be  taken  to  avoid  the  entrance  of  disinfectants  into  the  abdomen. 
Sublimate  and  its  substitutes  must  only  be  used  to  disinfect  the  lines 
of  suture  and  those  areas  of  peritonteum  which  have  been  direct^ 
contaminated  b}-  the  gastro-intestinal  contents.  Kocher  thinks  that 
collapse  is  often  due  to  the  too  free  use  of  such  disinfectants.  Even 
during  a  very  prolonged  operation,  salt  solution  should  be  employed 
exclusively  for  the  swabs,  and  all  the  gauze  placed  around  the  wound. 
To  prevent  the  entrance  of  gastro-intestinal  contents,  it  is  essential  to 
use  plent}-  of  soft  gauze.  (2)  As  advocated  by  Rydygier  and  Lauenstein, 
all  the  sutures,  the  superficial  serous,  and  the  deeper  which  take  up  the 
whole  thickness  of  the  wall,  must  he  contimious  and  without  the  least 
interruption  from  one  end  of  the  wound  to  the  other :  this  is  why 
Kocher  so  strongly  urges  lea^dng  the  ends  of  the  posterior  sutures 
long  after  knotting  them,  so  that  they  may  be  again  reliably  knotted 
with  the  anterior  sutures.  A  perfectly  secure  closure  is  thus  attained, 
and  there  is  not  the  slightest  necessity  to  prove  that  the  suture  is 
water-tight,  by  distending  the  intestine.  Another  reason  for  carr34ng 
the  continuous  suture  through  the  entire  thickness  of  both  gastric  and 
intestinal  walls  is  that  only  by  this  means  can  reactionary  hemorrhage, 
which  has  been  the  cause  of  a  certain  number  of  fatal  cases,  be 
prevented  with  certainty.  Fine  strong  silk  must  be  used  for  the 
sutiires,  not  the  less  reliable  catgut.  Kocher  has  not  seen  any  of 
the  disadvantages  ascribed  to  silk.  He  considers  that  Senn's  method 
is  more  complicated  than  his  own,  and  that  its  results  have  not 
quite  fulfilled  expectations.  (3)  The  employment  of  clamps.  Kocher 
considers  these  absolutely  necessary  for  the  closure  of  the  cancerous 
portion,  both  on  the  duodenal  and  the  gastric  side.  It  is  only  in 
this  way,  as  he  has  pointed  out  (Centr.  f.  Chir.,  1883,  No.  45),  that 
the  dangerous  escape  of  cancer  juice  can  be  prevented  with  certainty. 
The  clamps  have  the  following  additional  advantages — viz.,  that  the 
intestine,   and  more  especialh"  the  stomach,  can  be  cut  across  along 

*  The  intestine  is  held  vertically  against  the  stomach  while  it  is  being  siitiired,  and 
the  opening  in  the  stomach  is  made  vertically  also. 


PYLORECTO-MY   AND  GASTRO-DUODP:XOSTOMY.  32 1 

an  exact  line  at  the  place  desired,  a  matter  which  is  otherwise  not 
always  easy.  Further,  the  use  of"  clamps  greatly  shortens  the  operation. 
They  produce  complete  closure,  and  serve  as  convenient  handles  for 
drawing  up  and  manipulating  the  parts.  They  increase  the  possibility 
of  completely  disinfecting  the  cut  edges  immediately  after  the  section, 
by  preventing  their  slipping  back.  Lauenstein's  objection  that  they 
necessitate  removal  of  additional  sound  tissue  is  hardly  a  disadvantage, 
as  the  prospect  of  a  permanent  cure  is  thereby  increased.  As  to  other 
disadvantages,  Kocher  is  convinced  that  they  cause  no  necrosis  if  the 
operation  be  properly  and  aseptically  performed.  He  has  no  hesitation 
in  applying  a  clamp  to  the  healthy  part  of  the  duodenum  where  it  is 
afterwards  to  be  stitched.*  In  his  use  of  clamps.  Kocher  applies  no 
elastic  covering  after  the  manner  of  Gussenbavier,  nor  does  he  use 
the  elastic  bands  of  Rydygier.  He  merely  clamps  them  firmly  enough 
to  thoroughly  close  the  intestine  and  stomach,  and  has  observed  that 
the  edges  of  both  bleed  actively  as  soon  as  the  clamps  are  removed. 
Finally,  Kocher  denies  that  the  clamps,  by  requiring  unnecessary 
room,  necessitate  a  needless  separation  of  the  mesentery  as  stated  by 
Lauenstein. 

ii.  Combined  Pylorectomy  and  Gastro-duodenostomy  or  Gastro- 
enterostomy.— This  method,  the  adoption  of  which  is  becoming  more 
and  more  general,  bids  fair  to  become  the  recognised  method  of  perform- 
ing pylorectomy.  The  chief  advantages  are: — (l)  Great  rapidity  and 
simplicity,  especially  if  the  anastomosis  be  made  with  a  Murjihy's  button. 
(2)  It  is  as  easy  to  remove  a  considerable  portion  of  the  stomach  as  to 
excise  the  pylorus  only;  hence  the  surgeon  need  run  no  risk  of  not 
removing  the  growth  widely  enough.  The  primaiy  stages  of  the 
operation  are  similar  to  those  of  Kocher's  method  (p.  316).  After 
the  diseased  portion  of  the  stomach  has  been  removed,  the  cut  edges 
of  both  the  divided  stomach  and  duodenum  are  closed  by  two  rows 
of  silk  sutures,  the  first  continuous  and  including  all  the  coats,  the 
other  continuous  or  interrupted,  according  to  the  choice  of  the 
operator,  inverting  the  first  row  and  including  the  serous  and  muscular 
€oats  only. 

The  second  portion  of  the  operation  consists  in  the  performance  of  the 
gastro-jejunostomy.  which  is  carried  out  either  by  direct  suture  or  by 
means  of  Murphy's  button,  as  described  below  (p.  330). 

iii.  Pylorectomy,  with  direct  suture  of  the  divided  ends. 

Operation. — (Owing  to  the  time  this  method  takes  it  i^  not  to  be 
recommended.  It  ^\ili  be  described  out  of  respect  to  the  Continental 
surgeons  who  have  acted  as  pioneers  in  this  direction.) 

Various  incisions  have  been  made — viz.  :  (i)  A  vertical  one  in  the 
linea  alba,  above  the  umbilicus.  (2)  A  vertical  one  in  the  right  linea 
semilunaris,  or  through  the  rectus,  separating  its  fibres  so  as  to  avoid 
hcemorrhage  (p.  299).  (3)  Obliquely  from  above  downwards,  and  from 
within  outwards,  between  the  umbilicus  and  right  ribs.  (4)  More 
transversely  over  the  tumour.  Either  of  the  last  two  gives  more  room, 
and  thus  better  access  to  the  growth.     But  as  both  are  accompanied 

*  The  closure  of  the  cardiac  side  of  the  section  of  the  stomach  must  be  effected 
merely  by  the  hands  of  an  assistant. 

VOL.    II.  21 


322  OPERATIONS  ON   THE  ABDOMEN. 

with  more  haemorrhage,  and  are  much  more  difficult  to  close* — a  point 
which  may  be  of  much  importance  at  the  close  of  such  an  operation — 
they  should  not  be  made  use  of.  Suture  of  a  divided  retracted  rectus 
is  most  embarrassing  if  there  be  any  distension  of  the  abdomen.  All 
hasmorrhage  having  been  first  arrested,  the  transversalis  fascia  and  peri- 
tongeum  are  pinched  up  and  opened  so  as  to  admit  two  fingers,  which 
examine  the  growth  ;  and  note  the  presence  of  adhesions  or  enlarged 
glands,  invasion  of  the  liver,  pancreas,  or  colon,  or  curvatures  of  the 
stomach  itself.  If  the  disease  is  so  localised  as  to  allow  the  sm-geon  to 
go  on,  the  opening  in  the  peritonEeum  is  enlarged  so  as  to  get  a  better 
view  of  the  disease,  and  to  enable  the  mass  to  be  drawn  forwards  with 
vulsellum-forceps.  This  having  been  done  as  much  as  possible,  the 
stomach  is  packed  around  with  hot  carbolised  towels  or  sterile  gauze,  so 
as  to  prevent  any  escape  of  fluids  into  the  peritonteal  sac.  The  omenta 
are  next  separatedf  with  scissors,  either  between  double  ligatures  of 
chromic  gut  previously  passed  with  an  aneurysm  needle,  or  between 
large  pairs  of  omental  clamp-forceps ;  the  tissues  being  very  thin  it  is 
not  necessar}^  to  take  much  time  in  tying  them  bit  b}^  bit.  Any 
suspicious  lymphatic  glands  must  be  removed. 

Fig.  128. j 


Oblique  division  of  the  stomach  and  duodenum  in  pylorectomy.  Billroth 
in  tliis  case  made  half  the  division  of  the  stomach  first,  united  this  with 
"occlusion  sutures,"  next  severed  the  rest  of  the  stomach,  then  the  duodenum, 
finally  uniting  this  to  the  greater  cui-vature.     (Billroth.) 

l^xcision  of  the  Diseased  Pi/lorxis. — Previous  to  this,  iodoform-gauze 
tampons  sliould  be  still  more  carefully  packed  around  the  stomach, § 
and  the  duodenum  should  be  secured,  either  with  some  foi'm  of 
clamp  (Fig.  125),  or  by  a  strip  of  iodoform-gauze  clamped,  or  held  by 
an  assistant's  fingers,  wide  of  the  disease.     The  duodenum  is  then  cut 


*  In  Mr.  Southam's  case,  the  incision,  six  inches  long,  was  made  two  inches  above 
the  umbilicus,  and  across  both  recti ;  the  contraction  of  these  muscles  led  to  much 
difficulty  in  adjusting  the  abdominal  wound. 

f  Care  must  be  taken  only  to  detach  the  omenta  over  the  area  corresponding  to  that 
which  is  to  be  removed. 

X  This  and  the  next  four  figures  arc  taken  from  Prof.  Billroth's  Clinical  Surr/eri/, 
part  iii. 

§  It  will  add  greatly  to  the  safety  of  the  operation  if  the  pylorus  can  be  so  drawn 
out  of  the  wound  that  a  flat  sponge  can  be  placed  within  the  peritonteal  sac,  and 
iodoform  gauze  packed  around  the  now  isolated  pylorus. 


PYLORECTOMY.     EXCISION   OF  TIIE  PYLORUS. 


323 


through,  as  in  Fig.  128,  with  scissors,  at  least  half  an  inch  from  the 
disease.  This  incision,  oblique,  so  as  to  diminisli  as  far  as  possible  the 
difference  in  the  openings  in  the  stomach  and  duodenum,  is  made  with 
a  series  of  clean,  careful  snips,  any  bleeding  points  being  secured  at 
once  with  Spencer  Wells's  forceps  if  few,  and  with  fine  chromic  gut  if 


Fig. 


129. 


Duodenum  united  to  the  greater  curvature ;   ten  occlusion  sutures  unite  the 
upper  part  of  the  cut  stomach.     (Billroth.) 

numerous.  Any  fluid  which  escapes  must  be  mopped  up  with  or 
caught  on  aseptic  gauze,  and  a  small  sponge,  fastened  to  string,  may 
be  introduced  into  either  viscus,  if  it  will  facilitate  the  suturing.  This 
step  may  also  be  rendered  easier  by  dividing  the  stomach  only  partially 
at  first,  suturing  this  part  and  then  completing  the  division.     All  the 

Fig.  130. 


(Billroth.) 

sutures  should  not  be  cut  short  as  tied ;  if  the  operator  leaves  some  long 
(clamped  in  forceps,  so  as  not  to  be  in  the  wa}')  it  ma}'  give  him  a 
useful  hold  on  the  viscera  he  is  uniting.  Dr.  Adams  (loc.  supra  cit.) 
found  that  a  free  removal  of  the  mucous  membrane  from  the  edges  of 
the  wound  greatly  facilitated  uniting  them. 

Tlie  section  of  the  stomach  has  been  made  in  different  ways.     ITie 
most  usual  one  is  shown  in  Fig.  128.     The  section  is  made  obliquely. 


0-4 


OPERATIONS  OX  THE  ABDOMEN, 


with  the  precautions  ah-eady  given  in  the  case  of  the  duodenum. 
As  the  cut  end  of  the  stomach  is  so  much  larger  than  that  of  the 
duodenum,  the  former  must  be  reduced  by  suturing  part  of  it  before 
it  is  completelj^  divided.  The  surgeon  will  decide  ^^■hether  he  will  unite 
the  duodenum  to  the  greater  or  lesser  curvature,  or  to  the  part  between 
the  two.*  In  the  fomuer  case  he  cuts  the  stomach  from  above  down- 
wards, and  from  left  to  right,  and  it  will  be  well  to  unite  that  part 
of  the  stomach  which  will  be  superfluous  before  the  section  is  completed 
(Fig.  129).  The  same  course  is  followed  if  the  duodenum  is  united  to 
the  lesser  curvature  ;  but  hei"e  the  section  is  made  from  below  upwards, 
and  from  right  to  left.  Figs.  130,  131,  show  the  mode  of  uniting  the 
duodenum  midway  between  the  two  curvatures. 

Closure  of  the  Stomach,  and  Union  of  this  and  the  Duodenum. — 
That  part  of  the  stomach  which  is  superfluous  is  closed  with  carbolised- 


FiG.  131. 


Fig.  132. 


(Billroth. 


Insertion  of  the  posterior  ring  sutnres 
from  -within.     (Billroth.] 


silk  sutures,  inserted  by  Lembert's  method,  the  sutures  being  left  long 
and  held  in  forceps,  so  as  to  steady  and  move  the  stomach,  and  thus 
facilitate  its  union  with  the  duodenum.  The  clamp  on  the  latter  being- 
removed,  it  is  united  to  the  greater  or  lesser  curvature,  or  centre,  as 
follows,  beginning  with  sutures  passed  from  within  (Fig.  132).  These, 
of  fine  carbolised  silk,  are  passed  with  a  needle  in  a  holder,  first  at  the 
cut  edge  of  the  stomach  betweea  the  mucous  and  muscular  coats, 
carried  on  between  the  muscular  and  serous,  then  through  the  same 
layers  of  the  duodenum,  and  finally  brought  out  bet\\-een  these  layers 
and  the  mucous  membrane  at  the  cut  edge  of  the  duodenum.  When 
the  posterior  aspect  of  the  two  viscera  is  thus  soundly  closed,  the 
anterior  one  is  united  by  Lembert's  suture.  The  needles  employed 
are  fine  curved  ones  for  the  sutures  inserted  from  within,  and  round 
straight  ones  (No.  5)  for  the  rest.  If  there  is  any  doubt  as  to  the 
security  of  the  sutures,  an  omental  graft  may  be  used  (Figs.  100,  lOi, 
and  102).  Dr.  Adams  employed  one  of  these  in  his  case  (Brit.  Med.  Journ., 
1896,  vol.  i.  p.  966),  Avhere  he  employed  but  one  row  of  catgut  sutures. 

Care  must  be  taken,  in  inserting  the  sutures,  to  avoid  the  formation 
of  any  folds  (Billroth).  The  same  surgeon  says  it  is  well  to  put  a 
few  additional  superficial   sutures  at   the  point   where  the   borders  of 


Prof.  Billroth  prefers  uniting  the  duodenum  to  the  greater  curvature. 


PYLORECTOMY.   GASTRECTOMY.  325 

the  duodenum  join  those  of  the  stomach.  If  the  stomach  contains 
iluid  in  spite  of  the  washing  out,  it  must  be  mopped  dry  with  car- 
bolised  sponges  kept  for  tliis  purpose  alone,  and  it  may  be  a  help  to 
introduce  sponges  tied  on  to  silk  into  the  cut  ends  while  the  sutures 
are  being  inserted,  withdrawing  them  before  the  stitches  are  tightened. 
The  sutures  being  carefully  looked  over  and  cut  short,  a  little  iodoform 
is  rubbed  in,  the  gauze  or  towels  removed,  and  the  stomach  replaced. 
If  any  fluids  have  escaped  into  the  peritonaeal  sac,  this  must  be  care- 
fully cleansed  (p.  216).  The  abdominal  wound  is  then  closed  in  the 
usual  way  and  the  dressings  applied. 

After-treatment. — This  will  be  conducted  on  much  the  same  lines 
as  after  gastrotomy  (p.  31 1).  Mr.  Butlin  (loc.  supra  cit.)  points  out 
that  these  patients,  much  let  down  and  exhausted,  will  not  last  long- 
on  the  administration  of  ice  and  nutrient  enemata  onl}-.  After  the 
first  twenty-four  hours,  teaspoonfuls  of  milk,  Valentine's  meat-juice, 
raw  beef-juice,  barley-water,  and  a  few  drops  of  brandy  or  champagne, 
should  be  given,  at  first  every  half-hour  or  hour,  and  gradually  in- 
creased up  to  two  pints  in  the  twenty-four  hours  at  the  end  of  a  week. 

iv.  Pylorectomy,  the  ends  being  directly  united  by  some  such, 
means  as  Mayo  Robson's  bobbin,  &c. — Bj  this  means  the  time 
consumed  by  direct  suturing  is  considerably  shortened.  Dr.  Eawdon, 
of  Liverpool,  was,  I  believe,  the  first  in  this  country  thus  to 
improve  the  technique  of  pj^lorectomj^  (Brit.  Med.  Jovrn.,  1 890, 
vol.  i.  p.   323). 

After  division  of  the  omenta  (^vlde  supra,  p.  322)  and  resection  of  the  diseased 
pylorus,  the  stomach-opening  was  partially  closed  by  a  continuous  silk  Lembert's 
suture,  commencing  at  the  lesser  and  stopping  one  inch  from  the  greater  curvature, 
thus  leaving  .an  opening  large  enough  to  admit  a  Senn's  plate  cut  circular.  A 
similar  plate  was  introduced  into  the  duodenum,  all  four  silk  threads  being  passed 
through  the  walls  a  short  distance  from  the  cut  edges.  The  case  recovered  and  lived 
for  five  years,  nearly  foi;r  of  these  being  passed  in  perfect  health.  Three  years  and 
eight  months  after  the  operation' hsematemesis  occurred,  followed  six  months  later 
by  dyspepsia  and  a  small  swelling  under  the  cicatrix,  which  steadily  increased.  At 
the  necropsy  nearly  the  whole  of  the  stomach  was  occupied  by  a  large  ulcer.  There 
were  no  secondary  growths.  The  close  of  the  case  is  given  (^Lancet,  July  13,  1895) 
by  Dr.  W.  H.  C.  Davey,  to  whom  we  are  also  indebted  for  the  account  of  Dr.  Rawdon's 
operation. 

Mayo  Robson's  bobbin  will  be  an  improvement  on  the  above  method. 
Full  directions  for  its  use  in  end-to-end  junctions  are  given  at  p.  241. 
But  though  by  the  above  mechanical  means  the  lengthy  process  of 
suturing  will  be  rendered  shorter  and  safer,  the  difiiculty  of  adjusting 
securely  the  larger  stomach  end  to  the  smaller  duodenum  still  remains, 
and  for  these  reasons  methods  i.  and  ii.  are  certainly  preferable. 


GASTRECTOMY, 

Removal  of  the  A\liole  or  part  of  the  stomach  for  cancer  has  no\\'  been 
successfully  accomplished  a  number  of  times  by  different  surgeons.  The 
operation  is  indicated  when  it  is  found,  on  abdominal  exploration,  that 
the  stomach  is  infiltrated  with  cancer,  but  that  extensive  adhesions  and 
secondary  deposits,  either  in  other  organs  or  in  the  lymphatic  glands,  are 


326  OPERATIONS  ON  THE  ABDOMEN. 

absent.  Mayo  Eobson  (loc.  supra  cit.)  gives  a  list  of  eight  cases  of 
complete  gastrectomy  with  four  deaths — a  mortality  of  50  per  cent. — 
and  also  a  list  containing  fourteen  cases  of  partial  gastrectomy,  in  which 
at  least  three-fourths  of  the  stomach  were  removed.  The  mortality  in 
these  fourteen  cases  only  amounted  to  28*5  per  cent. 

As  regards  the  method  of  operating,  the  plan  most  usually  adopted  is 
to  remove  the  diseased  area,  as  described  above  under  pylorectomy 
(p.  316),  and  then  to  perform  a  gastro-enterostomy  by  one  of  the 
methods  described  below  (p.  328),  after  comjiletely  closing  both  the 
divided  ends  of  the  stomach.  In  some  cases,  however,  other  methods 
have  been  employed.  In  a  very  successful  case,  operated  upon  by 
Dr.  Harvie,  of  New  York  (Ann.  of  Surg.,  March  1900,  p.  344),  the 
duodenum  and  oesophagus  were  united  by  direct  suture. 

The  patient  was  a  woman,  aged  46,  who  had  had  gastric  symptoms  for  eighteen 
months  before  operation.  On  examination,  a  rounded  tumour  could  both  be  seen  and 
felt.  The  operation  was  rendered  difficult  by  adhesions  both  in  front  and  behind  the 
stomach,  practically  the  whole  of  which  was  infiltrated  and  thickened.  The  entire 
stomach  was  removed,  and  the  cut  surfaces  of  the  oesophagus  and  duodenum  united  by 
means  of  sutures.  "  The  entire  time  consumed,  from  the  first  incision  until  the 
abdomen  was  closed,  was  one  hour  and  five  minutes.  There  was  little  .or  no  loss  of 
blood."  The  subsequent  progress  was  most  satisfactory,  nourishment  being  first  given 
by  the  mouth  on  the  eighth  day.  The  patient  left  the  hospital  six  weeks  after  the 
operation,  "  after  taking  a  dinner  consisting  of  roast  beef,  mashed  potatoes,  ice-cream, 
cup  of  coffee,  and  one  glass  of  milk." 


GASTRO-JEJUNOSTOMY.* 

The  object  of  this  operation  is  to  make  an  opening  between  the 
blocked  stomach  and  the  small  intestine  as  high  up  in  the  latter  as 
possible,  so  that  the  food  may  still  find  its  way  into  the  intestine  and 
there  meet  with  the  other  digestive  fluids. 

Indications. — It  may  be  made  use  of  (A)  in  malignant  disease  of 
the  stomach  under  the  two  following  conditions  chiefly :  (i)  Together 
with  'pylorectomy  or  partial  gastrectomy  (p.  325). — This  is  always  to  be 
preferred  to  an  end-to-end  union.  This  combination  of  opei'ations  has 
given  good  results  (p.  321);  it  enables  us  to  attemj)t  the  removal  of 
the  disease,  and  at  the  same  time  greatly  shortens  the  operation. 

(ii.)  Alone. — This  is  clearly  a  very  inferior  operation  to  those  of 
pylorectomy  or  pjdorectomy  and  gastro-jejunostomy  combined.  If  all 
the  cases  of  gastro-jejunostomy  which  have  been  performed  had  been 
published,  it  is  practically  certain  that  the  results  both  as  regards  the 
immediate  mortalit}-  and  the  duration  of  life  would  be  most  disappoint- 
ing. This  is  no  doubt  due  to  the  fact  that  the  operation  has  been  far 
too  often  performed  in  very  emaciated  patients,  quite  unfit  to  bear  a 
prolonged  operation  and  to  supply  the  necessary  plastic  rej)air.  For 
the  future,  gastro-enterostomy  or,  as  it  should  be  here  more  correctly 

*  To  be  accurate,  the  term  gastro-jejunostomy  should  be  used  for  union  of  jejunum 
to  stomach,  gastro-duodenostomy  for  union  of  duodenum  and  stomach  after  a  pylorec- 
tomy (p.  316).  The  term  gastro-enterostomy,  which  has  been  carelessly  used  for  either 
of  the  above  operations,  should  be  dropped.  In  future,  writers  should  specify  which 
operation  they  refer  to. 


GASTEO-.JE.JUXOSTOMY.  32/ 

called,  gastro-jejuiiosfomv.  should  be  reserved  for  the  following  cases  of 
P3'loric  cancer:  (i)  "Where  the  malignant  disease  extends  too  far  into 
the  stomach,  or  where  it  is  too  fixed — e.g.,  to  liver  or  pancreas — to 
make  either  a  pylorectomy,  or  a  partial  or  complete  gastrectomy,  justifi- 
able :  or  where  secondary  deposits  and  enlarged  glands  can  be  felt. 
(2)  Where  the  cachexia  and  emaciation*  of  the  patients  are  not  so 
marked  that  it  is  very  doubtful  whether  they  will  survive  an  operation 
that  may  be  prolonged,  and  which  must  be  severe,  in  that  it  necessitates 
the  handling  of  very  xital  parts,  and  for  its  success  entails  a  certain 
adequate  amount  of  plastic  repair. 

If  the  operation  be  carefully  reserved  for  the  above  cases  it  will  be 
called  for  less  frecjuently  than  of  late  years,  but  will  be  found  in  these 
to  give  great  relief.  If  surgeons  continue  to  perform  it,  as  gastrostomy 
has  been  too  often  performed  for  malignant  disease  of  the  oesophagus, 
in  cases  where  the  operation  comes  too  late,  their  patients,  if  they 
survive,  will  do  so  for  a  very  short  time,  succumbing  to  the  effects  of  a 
marasmus  so  established  as  to  be  unalterable.  Dr.  Murphy,  of  Chicago. 
goes  further  (Lancet,  1895,  "^'o^-  i-  P-  1040) :  "  It  is  my  opinion  that 
patients  who  are  not  in  a  condition  to  stand  a  pylorectomy  f  should  not 
be  operated  upon.  The  relief  obtained,  even  when  gastro-enterostomy 
is  successful,  is  so  limited  that  it  does  not  justify  the  danger  and  dis- 
comfort produced  by  the  operation,  notwithstanding  that  the  operation 
can  be  performed  with  the  button  in  from  five  to  seven  minutes.  These 
patients  suffer  much  more  from  shock  in  operation  than  those  with 
non-malignant  disease,  and  the  regenerative  power  of  the  tissues  with 
malignant  disease  is  much  impaired." 

(B)  In  certain  cases  of  non- malignant  pyloric  stenosis  in  which 
pyloroplasty  is  not  available  (vide  sujrra).  e.g.,  where  there  is  great 
hypertrophy  of  the  pylorus,  extensive  adhesions,  or  active  ulceration. 

(C)  In  chronic  ulcer  of  the  stomach  when  situated  near  the  pylorus, 
or  causing  severe  hfemorrhage,  which  cannot  be  treated  by  the  other 
means  described  above  (vide  p.  308).  When  the  patient,  owing  to 
severe  haemorrhage,  is  unfit  to  undergo  a  prolonged  search  for  the  ulcer, 
or  when  the  ulcer  is  adherent  and  on  the  posterior  wall  of  the  stomach, 
gastro-jejunostoniy  should  be  performed.  In  the  majoi-ity  of  the  cases 
in  which  this  has  been  done  complete  relief  has  followed. 

Operation. — The  preliminaries  are  the  same  as  those  already  given 
for  pylorectomy  (p.  3i6).|  The  abdomen  having  been  opened,  the  next 
point  is  to  make  sure  of  finding  the  jejunum  as  high  up  as  possible. 
The  omentum  and  colon  having  been  pushed  upwards  and  to  the  right, 
the  duodeno-jejunal  junction  must,  if  possible,  be  seen  as  well  as  felt 
where  it  lies  below  the  pancreas  close  to  the  vertebral  column ; 
these  last  two  being  good  landmarks  to  feel  for.     This  is  one  of  the 


*  Instances  which  do  and  which  do  not  justify  gastro-jejunostomy  would  be  cases 
where,  on  the  one  hand,  the  loss  has  been  only  two  pounds  in  several  months,  and,  on 
the  other,  that  of  a  stone  in  a  week  or  two. 

t  By  this  is  meant  a  pylorectomy  shortened  by  the  combined  operation  with  a 
gastro-duodenostomy  (p.  321). 

X  Some  Continental  surgeons,  in  order  to  avoid  the  risk  of  after-vomiting,  have 
made  use  of  cocaine  only.  In  an  operation  like  this,  of  uncertain  length,  and  requiring 
absolute  stillness,  general  anaesthesia  is  certainly  to  be  preferred.   " 


328  OPERATIONS  ON  THE  ABDOMEN. 

essential  points  in  the  operation.  If  the  piece  of  small  intestine  which 
emerges  below  the  colon  be  chosen,  it  may  prove  to  be  low  down  in  the 
ileum.  If  the  wrong  end  of  the  small  intestine  be  thus  attached  to  the 
stomach,  the  food  taken  will  not  be  subjected  to  the  natural  processes 
of  digestion  and  absorption  and  the  prolongation  of  life  will  be  brief. 
The  importance  of  the  above  is  proved  by  the  fact  that  tlie  above 
accident  has  occurred  to  operators  of  such  experience  as  Mr.  H.  W.  Page 
{Med.-Ghir.  Trant^.,  vol.  Ixxii.  p.  379).  Here  the  intestine  attached  to 
the  stomach  was  the  ileum,  nine  inches  from  its  lower  end.  This  patient 
lived  for  ten  weeks,  and  though  greatly  relieved  from  vomiting  and 
nausea,  began  to  lose  ground  at  the  end  of  six  weeks.  Mr.  Page  quotes 
some  other  cases,  a  striking  one  being  that  of  Lauenstein(Cew!^./.  Chir., 
1888,  p.  472).  Here  the  intestine  opened  was  only  fifteen  inches  from 
the  ileo-csecal  valve.  The  patient  began  to  have  diarrhoea  on  the  fourth 
clay,  passed  unchanged  food  in  her  stools,  and  died  on  the  eleventh  da5^ 

The  jejunum  having  been  made  certain  of,  high  up  in  its  course,* 
it  may  be  united  to  the  stomach  by  one  of  the  following  methods : 
(i)  Suturing  alone;  (2)  Murphy's  button;  (3)  a  decalcified  bone 
bobbin  ;  (4)  Laplace's  forceps.  Of  the  above  the  first  three  have  been 
largely  tried.  Of  the  different  methods  of  suture  alone,  I  think  Halsted's 
should  be  preferred,  as  giving  a  very  large  opening  with  ample  margin 
for  contraction  and  a  very  efficient  suture.  Senn's  plates  simplify  the 
operation  greatly;  but  it  is  certain  from  the  cases  recorded  that  the 
opening  is  liable  to  contract  most  seriously  later  on.  Murphy's  button 
has  scored  very  brilliant  successes  ;  it  is  the  simplest  and  quickest  of  all 
the  methods,  and  may  be  resorted  to  when  the  patient's  condition  does 
not  justify  an}^  more  prolonged  method,  such  as  suturing.  As  I  have, 
however,  stated  in  the  account  of  enterectomj^,  the  very  simplicity  of 
this  most  ingenious  instrument  has  led  to  its  being  largely  resorted  to, 
and  I  am  of  opinion  that  there  are  a  considerable  number  of  cases  in 
which  it  has  not  been  successful,  and  which  have  never  been  reported. 
The  decalcified  bone  bobbin  has  not  yet  been  sufficiently  used  in  gastro- 
jejunostomy for  a  definite  opinion  to  be  given  ;  but,  judging  from  its 
success  in  operations  on  the  intestine,  and  its  numerous  proved  advan- 
tages, I  expect  to  see  it  come  largely  into  use  here  also  (vide  also  p.  338). 

(i)  Gastro-jejunostomy  by  Suture  alone.  (A)  Halsted's  Method. 
— This  has  been  figured  and  described  at  p.  270.  Mr.  Bidwell  brought 
a  case  of  gastro-jejunostomj^,  performed  in  this  way,  before  the  Clinical 
Society  (Trans.,  1894,  p.  11).  The  following  is  taken  from  his  account 
of  the  operation  : — 

"A  portion  of  the  jejunum  was  held  in  contact  with  the  anterior  wall  of  the  stomach 
near  the  cardiac  end,  both  being  brought  outside  the  wound  and  packed  around  with 
sponges.  Six  quilt  sutures  (Fig.  106)  were  then  passed  between  the  jejunum,  half  an 
inch  from  its  mesenteric  attachment  and  the  anterior  wall  of  the  stomach.  No.  8 
straw  needles  had  been  previously  threaded  with  No.  g  silk,  and  a  separate  needle  was 
used  with  each  suture ;  the  ends  of  each,  when  passed,  were  clamped  with  pressure- 
forceps.  Great  care  was  taken  to  pick  up  aiid  include  in  each  suture  some  fibres  of  the 
submucous  coat,  as  strongly  recommended  by  Dr.  Halsted.  Three  sutures  were  then 
passed  at  the  end  of  this  row  of  sutures,  and  all  twelve  were  then  tied  and  the  ends 
cut  short.    Six  similar  sutures  were  then  inserted  about  five-eiu:hths  of  an  inch  in  front 


*  A  sufficient  length  of  the  jejunum  must  be  allowed  for,  so  that  it  can  be  brought 
easily  round  the  colon  (Fig.  141,  p.  336). 


GASTKO-JEJUXOSKJMY.  329 

of  the  former  row.  and  each  was  clamped  with  forceps!.  An  opening  about  an  iiich 
long*  was  then  made  into  the  jejunum  and  stomach  between  the  two  rows  of  sutures. 
Some  frothy  mucus  and  blood  escaped  from  the  stomach,  and  the  growth,  which 
appeared  to  completely  occlude  the  pyloric  orifice,  was  easily  explored  by  the  finger. 
A  point  of  suture  was  used  to  unite  the  mucous  membranes  of  stomach  and  jejunum 
above  and  below,  and  the  anterior  row  of  quilt  sutures  were  quickly  tied.  Some  boracic 
acid  solution  was  allowed  to  flow  over  the  part  while  the  sutures  were  being  tied.  The 
anastomosis  was  now  complete."  The  patient  had  great  relief  during  the  five  weeks 
which  he  survived. 

Mr.  Bidwell  believes  that  this  method  of  Dr.  Halsted's  will  effect  a 
more  satisfactory  union  than  Senn's  plates  without  taking  much  longer 
in  application.  Though  he  had  not  used  the  method  before,  he  was 
able  to  effect  the  anastomosis  in  twenty-five  minutes.  He  draws  atten- 
tion to  the  need  of  turning  the  loop  of  jejunum  half  round  after  it  has 
been  picked  up,  so  that,  when  it  is  fixed  to  the  stomach,  the  axes  of 
peristaltic  action  correspond  in  the  two  viscera. 

(B)  Barker's  Method. — While  I  have  stated  above  why  I  consider 
Halsted's  method  the  best.  I  shall  describe  an  alternative  method  which 
has  been  used  successfully.  It  is  that  given  by  Mr.  Barker  (Brit.  Med. 
Jour  a.,  Feb.  13,  i886j: — 

After  pushing  the  omentum,  which  was  not  voluminous,  to  the  left,  the  first  part  of 
the  jejunum  f  was  caught  in  the  fingers,  and  a  loop  drawn  out  of  the  incision.  The 
middle  of  the  anterior  surface  of  the  stomach  J  was  also  drawn  out,  and  supported  all 
round  by  warm  carbolised  sponges.  I  now  passed  a  piece  of  india-rubber  tubing  through 
the  mesentery  at  each  end  of  the  loop,  and,  having  emptied  the  portion  of  gut  by  gentle 
pressure,  drew  the  ends  of  the  tubing  tight  enough  to  prevent  access  of  the  contents  of 
the  bowel  into  the  loop  to  be  operated  on,  and  fixed  each  piece  of  tubing  with  catch- 
forceps.§  The  empty  loop  of  gut  was  now  laid  upon  the  portion  of  stomach  to  be 
opened,  and  a  longitudinal  fold  of  the  latter,  about  an  inch  and  a  half  from  the  great 
curvature,  was  pinched  up  between  the  finger  and  thumb  of  the  left  hand,  together 
with  the  collapsed  gut.  I  now  made  an  incision  about  an  inch  and  a  half  long  in  the 
fold  of  the  stomach,  and  another  corresponding  in  the  approximated  fold  of  gut.  These 
incisions  only  penetrated  through  the  serous  and  muscular  tunics,  and  left  the  mucous 
coat  of  both  viscera  intact  for  the  present.,;  Still  holding  the  parts,  as  before,  between 
finger  and  thumb,  I  now  united  the  corresponding  posterior  edges  of  the  wounds 
by  a  continuous  suture,  the  needle  entering  and  emerging  in  each  case  between 
the  mucous  and  muscular  coats,  and  the  threads  crossing  the  cut  edges  of  the 
muscular  and  serous  coats.  In  this  way  the  serous  surfaces  were  closely  united 
from  end  to  end  before  either  viscus  was  opened.  This  row  of  stitches  (which 
were  about  one-eighth  of  an  inch  apart)  was  carried  about  a  quarter  of  an  inch 
beyond  each  end  of  the  incision  in  the  coats  of  the  bowel.  The  moment  had  now 
come  to  open  both  the  stomach  and  intestine  completely,  and  this  was  done  with 
a  stroke  of  scissors  through  the  mucous  coat  in  each  case,  special  sponges  being  ready 
to  receive  any  fluitl  which  might  escape.    A  few  drachms  of  succus  entericus  flowed  from 

*  The  opening  should  be  much  more  free,  as  a  rule,  for  fear  of  contraction. 

t  The  part  actually  brought  up  to  the  stomach  must  be  about  twelve  or  fifteen 
inches  from  its  commencement,  so  as  to  come  up  without  any  tension. 

%  The  part  of  the  stomach  chosen  must  always  be  as  far  as  possible  from  the  disease. 
And  when  the  stomach  walls  are  thin  and  atrophieil  the  opening  must  be  as  low 
as  possible,  as  the  contents  will  have  to  find  their  way  out  hy  gravity  alone. 

§  If  this  method  be  made  use  of.  care  must  be  taken  not  to  puncture  anj'  vein  in  the 
mesentery,  or  most  troublesome  bleeding  will  follow.  Other  modes  of  clamping  the 
intestine  will  be  found  at  p.  259. 

li  Most  troublesome  bleeding  followed  on  these  incisions,  both  in  the  intestine  and 
the  stomach,  in  Mr.  Pasre's  case. 


)30 


OPERATIONS  ON  THE  ABDOMEN. 


the  bowel — little  or  nothing  from  the  stomach  opening.  After  careful  cleansing,  the 
anterior  borders  of  both  openings  were  now  united  by  a  row  of  interrupted  fine-silk 
sutures,  introduced  according  to  Czerny's  method.  AVhen  this  was  completed,  the  two 
openings  were  securely  closed,  but,  as  an  extra  precaution,  the  intestine  was  turned 
over,  and  the  posterior  suture  was  reinforced  by  a  second  row  of  interrupted  sutures, 
placed  about  a  quarter  of  an  inch  away  from  the  first.  The  anterior  was  then 
similarly  reinforced  by  a  row  of  continuous  sutures  taking  up,  as  before,  only  the 
serous  and  muscular  tunics.  Lest  there  should  be  any  "  kinking  "  of  the  latter,  as  in 
one  of  Billroth's  cases,  I  stitched  its  efferent  portion  to  the  stomach  wall,  about  three- 
quarters  of  an  inch  from  the  right  extremity  of  the  opening  between  the  stomach  and 
jejunum." 

Mr.  Page  made  use  of  similar  steps  in  his  operation  to  which  I  have 
alluded.      The  following  excellent  drawings  (Figs.    133   and    134)   are 


Fig.  133. 


Fig.  134. 


Gastro-jejuuostomy  by  suture.  The  pos- 
terior edges  of  the  divided  stomach  and 
intestine  have  been  united  by  silk  sutui-es, 
extending  half  an  inch  beyond  the  openings, 
at  each  end.     (H.  W.  Page.) 


Int. 


Gastro-jejunostomy  by  suture. 
Final  union,  the  anterior  lips  of 
the  openings  in  the  viscera  hav- 
ing been  united.  (H.  W.  Page, 
Med.-Chir.  Trans.,  vol.  Ixii.) 


taken  from  those  accompanying  his  paper.  Some  sixty  silk  sutures 
were  used  altogether,  a  row  of  Lembert's  stitches  having  been  placed 
around  and  about  half  an  inch  from  the  closed  opening. 

(2)  Gastro-jejunostomy  toy  Murphy's  Button. — This  is  the  simplest 
of  all  the  methods  of  gastro-jejunostomy.  As  has  been  the  case  with 
this  most  ingenious  instrument  after  resection  of  the  intestine,  it  has 
scored  many  brilliant  successes,  but  in  both  cases  there  is  reason  to 
believe  that  the  extreme  simplicity  of  the  method  has  led  to  its  use  in 
many  cases  which  have  not  been  published  because  unsuccessful.  Dr. 
Murphy  in  1895  (Lancet,  vol.  i.  p.  104)  spoke  of  there  having  been 
twenty-seven  cases  with  nine  deaths.  Eesults  during  recent  years  have, 
however,  been  far  superior  to  this ;  for  instance,  Czerny  has  made  use  of 
this  method  more  than  a  hundred  times,  without  a  death  attributable  to 
the  button,  vide  also  the  results  given  on  p.  339.  In  four  of  the  fatal 
cases  in  Dr.  Murphy's  list,  death  occurred  from  exhaustion  before  the 


GASTRO-JEJUXOSTOM  Y.  3  3 1 

fourth  day,  and  it  is  stated  that  in  each  the  approximation  was  perfect. 
This  date  is  too  early  to  speak  with  confidence  of  the  approximation 
brought  about  by  the  button.  After  remaining  perfect  for  a  longer 
time  it  may  suddenly  fail,  as  in  the  following  case  of  my  own : — 

A  patient  of  Dr.  Pye-Smith's.  at  Guy's  Hospital,  aged  45,  was  transferred  to  my  care 
in  April  1895,  with  carcinoma  of  the  pylorus.  "When  the  stomach  was  exposed  the 
growth  was  too  extensive  to  admit  of  pylorectomy.  It  extended  for  an  inch  and  a 
half  into  the  pyloric  end  of  the  stomach,  and  sent  numerous  vascular  processes  along 
the  lymphatics  into  both  omenta.  I  united  a  loop  high  up  in  the  jejunum  to  the 
anterior  wall  of  the  stomach,  a  little  to  the  cardiac  side  of  the  centre  of  the 
anterior  wall  so  as  to  be  free  of  the  growth.  The  only  difficulty  in  the  operation  was 
making  certain  of  the  jejunum.  Every  step  of  the  union  of  the  viscera  was  rendered 
most  easy  by  the  button.  For  seven  days  the  course  was  uneventful  save  for  obstinate, 
fixed,  gnawing  pain  which  I  attributed  to  the  button  having  to  make  its  way  through 
a  thick-walled  viscus  well  supplied  with  nerves.  On  the  seventh  day  the  bowels  acted 
after  an  enema.  On  the  eighth  this  action  was  repeated,  and  a  small  slough  was  found 
in  the  stool.  Shortly  after,  symptoms  pointing  to  perforation  occurred,  -with  rapid 
collapse  and  death.  It  is  greatly  to  be  regretted  that,  as  the  man  was  one  of  the 
paying  hospital  patients,  no  necropsy  was  made. 

I  have  already-  (p.  238)  spoken  fully  of  what  I  consider  to  be  the 
dangers  of  the  Murphy  button.  It  is  fair  to  this  method  to  say  that  the 
carcinoma  was  here  extensive,  vascular,  and  growing  rapidly  in  a  com- 
paratively young  patient.  It  is  possible,  therefore,  that  in  spite  of  my 
precaution  I  may  have  placed  it  in  tissues  already  affected  by  growth 
and  thus  certain  to  soften  prematurely.  I  did  not  make  use  of  the 
V.  Hacker  position,  as  preferred  by  Dr.  Murph}',  because  the  anterior  or 
Wolfler  method  has  given  very  good  results,  and  because,  owing  to  the 
extension  of  the  growth  into  the  omenta,  I  was  unwilling  to  disturb  the 
parts  more  than  was  absolutely  needful.  The  button  should  be  passed 
by  the  fourteenth  or  twenty-first  day.  M.  Quenu  gives  the  following 
result  of  a  gastro-enterostomy  performed  by  means  of  a  button.  A  year 
after  the  operation  the  patient  (who  had  greatly  improved)  began  to  fail, 
and  died  sixteen  months  after  the  operation,  jaundiced  and  emaciated, 
but  without  vomiting.  The  button  was  found  in  the  stomach,  having 
caused  no  symptoms.  The  communication  between  the  viscera  was 
freely  open.  Eecurrence  of  the  carcinoma  had  in\olved  the  pancreatic 
and  bile  ducts. 

Dr.  Murphy  (loc.  supra  cit.)  gives  the  following  conclusion:  (i)  That 
gastro-jejunostomy  should  never  be  performed  on  an  extremely  cachec- 
tic patient.  (2)  The  von  Hacker  position  (p.  336)  is  preferable,  though 
that  of  Wolfler  may  be  used.  The  former  favours  the  passage  of  the 
button  into  the  intestine.  Out  of  the  cases  in  which  the  approximation 
has  been  made  to  the  anterior  wall  of  the  stomach,  the  button  has 
dropped  back  into  this  viscus  in  four ;  in  none  of  them  did  it  give  any 
unpleasant  results,  and  Dr.  Murphy  believes  that  it  would  have  passed 
as  soon  as  the  stomach  had  contracted  in  size  and  the  patient  was  up 
and  about.  (3)  Owing  to  the  poor  reparative  power  of  the  tissues  in 
these  patients,  it  is  well  to  scarify  with  a  needle  the  adjacent  peritongeal 
surfaces  of  stomach  and  intestine :  this  hastens  the  formation  of 
adhesions.  (4)  A  few  interrupted  supporting  sutures  between  the 
stomach  and  intestine,  half  an  inch  from  the  button,  may  be  necessary 
where   there   is    any   tension    on    the    parts.      (5)  The  patient   should 


332  OPERATIONS  OX  THE  ABDOMEN. 

receive    liquid   nourishment  as   soon   as  the   effects  of  the  anaesthetic 
pass   away. 

The  earlier  steps  of  the  operation  are  as  already  described.  In  placing 
the  button  in  the  stomach  and  jejunum  it  is  advisable,  as  recommended 
by  Carle  and  Fontino  (Arch.  f.  Min.  Chir.,  Bd.  Ivi.  Heft  i),  to  dispense 
with  the  purse-string  suture,  substituting  one  or  two  simple  sutures  at 
each  side  of  the  button  after  the  latter  has  been  forced  into  the  stomach 
or  intestine  through  as  small  an  incision  as  possible.  This  prevents  the 
puckering  produced  by  the  purse-string  suture,  and  ensures  uniform 
contact  between  broad  serous  surfaces,  Kammerer  (^Ann.  of  Surg., 
July  1900,  p.  30)  adopted  this  plan  in  eleven  successful  cases  of 
posterior  gastro-jejunostomj-,  and  speaks  strongly  in  favour  of  the 
method. 

(3)  Gastro-jejunostomy  by  means  of  Decalcified  Bone  Bobbins. — 
This  method  has  been  recommended  by  Mr.  Mayo  Robson  (Med.-Chir. 
Trans.,  vol.  Ixxv.  p.  4 19,  and  Brit.  Med.  Journ.,  vol.  i.  1900,  p. 628).  I  have 
alread3^  at  p.  241,  spoken  of  the  advantages  which  Mr.  Mayo  Robson's 
method  possesses,  especially  its  simplicity,  the  fact  that  it  leaves  only  a 
temporary  foreign  body  in  the  alimentary  canal,  and  the  adaptability  of 
this  method  to  so  many  operations.  From  the  success  which  the  bobbin 
has  met  with  elsewhere,  it  is  probable  that  two  other  conditions  needful 
for  a  good  result — viz.,  securit}^  against  leakage,  which  is  given  by  the 
double  continuous  suture,  and  the  avoidance  of  after-closure  b}'  securing 
a  continuity  of  mucous  surfaces  around  the  new  channel — will  be  gained 
here  also,  and  I  am  of  opinion  that  in  future  the  bobbin  deserves  an 
extended  trial  in  gastro-jejunostomy. 

Operation. — The  chosen  portions  of  the  stomach  and  intestine  are 
drawn  well  up  into  the  wound,  emptied,  and  held  in  position  by  forceps 
which  act  as  guides  to  the  spots  to  be  opened.  The  peritonaeal  sac 
having  been  thoroughly  shut  off  with  sterile  gauze,  two  continuous 
sutures,  one  sero-serous  and  securing  peritonseal  apposition  for  fully 
one-third  of  an  inch  from  the  opening  all  round;  the  other,  marginal 
and  muco-mucous,  when  dra\\n  tight,  firmly  applies  the  edges  of  the 
openings  in  the  stomach  and  jejunum  to  the  tube,  thus  preventing  any 
extravasation.  The  sero-seroiis,  on  a  curved  needle,  is  first  inserted, 
half  or  one-third  of  an  inch  from  the  spot  Avhere  the  viscera  are  to  be 
opened,  first  to  jejunum  and  stomach  alternately,  the  suture  taking  up 
peritonaeum  and  outer  muscular  coat  only.  This  suture  is  left  long  at 
the  end  where  it  begins,  and  when  the  extreme  opposite  end  is  reached 
it  is  not  unthreaded,  in  order  to  complete  the  suturing  after  the  bobbin 
has  been  inserted,  and  the  marginal  or  muco-mucous  suture  completed. 
The  viscera  are  then  opened,  the  openings  being  just  sufficient  to  admit 
the  bobbin,  but  before  its  insertion  the  marginal  suture,  which  may  be 
either  of  chromicised  gut  or  of  silk  stained  with  aniline,  is  applied 
from  right  to  left,  uniting  the  posterior  margins  of  the  two  visceral 
openings,  the  suture  including  mucous  membrane,  and  being  left 
long  on  the  right  and  kept  threaded  on  the  left.  The  bobbin  is  next 
inserted,  and  the  marginal  suture  then  proceeded  with  round  the  front 
until  the  tail  of  the  suture  is  reached  :  the  two  ends  are  then  tio-htened, 
tied  and  cut  short,  thus  uniting  the  mucous  surfaces  round  the  tube. 
The  serous  suture  is  then  proceeded  with  half  or  a  third  of  an  inch  from 
the  marginal  one  until  the  circuit  is  completed,  when  the  two  ends  are 


C4  ASTRO- JEJUXOSTOM  T. 


333 


tightened,  tied  and  cut  short.     When  the  anastomosis  is  complete,  the 
sutures   cannot  be  seen   OI.  Robson). 

(4)  Gastro-jejunostomy  by  means  of  Laplace's  Forceps. — This  in- 
strument, ah'eady  described  (p.  249),  is  used  in  the  following  manner 
for  the  performance  of  gastro-jejunostomy.  Although  the  forceps  are 
undoubtedly  a  great  assistance  in  holding  the  parts  and  placing  the 
sutures,  it  cannot  be  said  at  the  present  time  whether,  as  regards  effi- 
ciency, this  method  can  be  compared   with  the   three  well-tried  ones 

Fig.   135. 


Gastro-jejunostomy  with  Laplace's  forceps.     One  blade  of  the  forceps  lias  been 
inserted  into  the  stomach.     (Laplace.) 

Fig.  ic;6. 


Gastro-jejunostomj-  with  Laplace's  forceps.     Both  blades  are  inserted  in  the 
parts  to  be  approximated.     (Laplace.) 


which  have  already  been  described.  The  only  objection  which  suggests 
itself  is  that  as  the  edges  of  the  mucous  membrane  are  not  directlv 
united,  subsequent  contraction  of  the  opening  seems  someAvhat  probable ; 
whether  this  will  occur,  experience  alone  can  show.  The  instrument  is 
so  ingenious,  however,  that  at  all  events  it  merits  a  fair  trial. 

Operation. — The  parts  to  be  united  having  been  isolated  and  brought 
into  apposition.  '•  an  incision  is  made  in  each  part  to  be  anastomosed, 
about  the  length  of  the  diameter  of  the  rings  to  be  used."'  The  two 
blades  of  the  forceps  are  now  introduced  through  the  openings,  one 


334 


OPERATIONS  ON  THE  ABDOMEN. 


blade  into  the  stomach  and  the  other  into  the  intestine  (Figs.  135  and 
136).  The  forceps  are  now  closed  and  clamped,  thus  bringing  into 
contact  the  serons  coats  of  the  two  viscera  (Fig.  137),  and  sntuies  are 
introduced  "  except,  of  course,  at  the  small  place  where  the  instrument 
penetrates  the  stomach  and  the  gut."     Continuous  sutures  are  used  in 


Fig.  137. 


Gastro-jejunostomy  with  Laplace's  forceps.  The  forceps  are  closed  and 
clamped,  approximatiug  the  serous  membrane  of  stomach  to  intestine. 
(Laplace.) 

Fig.  138. 


Gastro-jejunostomy  with  Laplace's  forceps.     Sutures  have  heen  applied  cir- 
cularly; the  clamp  is  removed,  loosening  the  forceps.     (Laplace.) 


the  illustration,  but  any  suture  may  be  employed.  "  The  handles  are- 
made  to  raise  the  parts  up,  and  afford  support  as  well  as  a  broad  surface 
to  work  on.  Having  united  the  stomach  and  intestine,  as  far  as  is 
desired,  the  forceps  are  easily  loosened  by  removing  the  clasp  (Fig.  1 38). 
The  forceps  constituting  one  half  of  the  ring  is  now  loosened,  and  drawn 
out  with  a  semicircular  motion  (Fig.  139),  then  the  other  is  removed  in 


GASTRO-JEJUXOSTOMY. 


335 


the  same  way  (Fig.  139).     Finally,  one  or  two  more  stitches  are  applied 
to  close  the  opening  through  which  the  forceps  were  removed." 


Fig.  139. 


»?=^<"~ 


Gastro-jejunostomy  with  Laplace's  forceps.  One  half  of  the  forceps  is 
undamped  ;  its  grasp  upon  the  tissues  is  loosened,  and  it  is  removed  by 
a  semicircular  motion  through  the  small  unsutared  aperture.     (Laplace.) 

Fig.  140. 


Gastro-jejunostomy  wit^h  Lajjlace's  forceps, 
completed.     (Laplace.) 


The  operation  is 


In  describing  the  chief  methods  of  gastro-jejunostomy  I  have  confined 
myself  to  the  anterior  method  of  union  and  to  the  less  complicated  pro- 
cedures by  which  this  union  is  attempted.     In  order  to  facilitate  the 


336 


OPERATIONS  OX  THE  ABDOMEN. 


passage  of  food  into  the  intestines  and  lo  prevent  the  regni'gitation  of 
intestinal  contents — e.g..  Ijile,  pancreatic  juice,  and  fa?cal  fluids — into  the 
stomach,  certain  modifications  of  the  anterior  and  simpler  gastro-jejun- 
ostomy  have  been  introduced. 

Von   Hacker's  and   Courvoisier's   method  of   Gastro-jejunostomy 
(Figs.  141.  143  and  144). — Here  the  small  intestine  is  joined  by  suture 


Fig.  14; 


Fig 


Fk 


Gastro-jejuiiostomy  showu  diagrammatieally. 

Fig.  141.— M,  Stomach.  C,  Colon.  D,  Small  intestine,  i,  Mesentery. 
2,  Mesocolon.  3  and  4,  Great  omentum.  The  parts  are  here  shown  in  their 
natural  i-elations.  The  arrow  a  shows  the  anterior  operation  after  the  method 
of  Wolfler ;  that  marked  d,  the  method  of  von  Hacker. 

Fig.  142. — Gastro-jejunostomy  according  to  Wolfler. 

Fig  143. — The  method  of  von  Hacker.  The  numbers  and  letters  have 
the  same  meaning  as  before.     (Von  Esmarch  and  Kowalzig.) 

to  the  posterior  wall  of  the  stomach.  The  stomach  and  omentum  having 
been  pushed  upwards,  a  piece  of  intestine  high  up  in  the  jejunum  is 
made  use  of  as  before,  emptied,  and  kept  so  either  by  clamps  or  b}'  a 
ligature  of  drainage-tube  tied  round  it,  and  lightly  clamped  with  a  pair 
of  Spencer  Wells's  forceps.     With  a  blunt  instrument,  an  opening  is 

torn  through  the  transverse  meso- 
colon at  a  spot  where  there  are  no 
vessels,  the  edges  of  this  opening 
are  then  united  b}-  a  few  points  of 
suture  to  the  hinder  wall  of  the 
.stomach,  and  then  the  loop  of 
jejunum  fixed  by  sutures  in  this 
gap  to  the  hinder  wall  of  the 
stomach  also.  The  transverse 
colon  with  the  great  omentum 
occup3"  afterwards  their  normal 
position  in  front  of  the  small  in- 
testine. 

For  this  method  the   followinof 
advantages    are    claimed:    (i)    It 
facilitates  drainage  of  the  dilated 
stomach,  thus  tending  to  diminish 
flatulence   and    dyspepsia ;    (2)  It 
diminishes    the    risk    of  regurgi- 
tation of  fluids  from  the  intestine  into  the  stomach;  (3)  This  method, 
b}^  joining  the   intestine  to  the  stomach   through  an  opening   in  the 
transverse  mesocolon,*  and  so  below  the  transverse  colon,  avoids  the 

*  The  feebleness  of  the  small  intestine  and  the  fact  that  it  has  been  strangled  in 
apertures  in  the  omentum  and  in  the  foramen  of  Winslow  must  here  be  remembered. 


Gastro-jejunostomy  liy  the   metliod    of   von 
Hacker.     (Von  Esmarch  and  Kowalzig.) 


G  A  STRO- JE  J  UNOSTOM  Y . 


337 


risk    of    strangulation    of  the    large   intestine,    or    at    all    events    the 
occurrence  of  tympanites  which  may  arise  from  its  compression. 

Wolfler's  and  Kocher's  Modifications  of  Gastro-jejunostomy. — 
Wdlfler  drew  attention  to  the  fact  that  the  long  axis  of  the  jejunum 
nnist  l)e  applied  to  that  of  the  stomach  in  such  a  wa}-  as  to  secure  the 
direction  of  the  onward  How  of  the  contents  of  the  two  viscera  corre- 
sponding— i.e.,  that  the  proximal  portion  of  the  jejunum  be  to  the  left 
and  the  distal  to  the  right.  Not  satisfied  with  this,  he  went  farther,  and 
in  order  to  prevent  any  entrance  of  the  contents  of  the  intestine  into 
the  stomach,  he  tried  to  form  a  valve-Hap  over  the  afferent  end  of  the 
knuckle  of  intestine  (Fig.  145).  Thus,  while  he  stitched  the  afferent 
half  of  the  opening  in  the  intestine  to  the  coats  of  the  stomach,  where 
still  intact,  he  united  the  efferent  half  only  to  the  edges  of  the  opening 
in  the  stomach.  The  same  authority  maintained  that  the  same  object 
could  be  obtained  in  the  following  way  (Fig.  146).  The  knuckle  of 
jejunum  is  cut  quite  through,  the  lower  end  is  united  to  the  opening  in 


Fig.  145. 


l-"l(i.  146. 


Gastro-jejunostomy  by  Wolfler's  method. 
(Von  Esmarch  and  Kowalzig.) 


Gastro-jejunostomy  by  another  method 
of  Wolfler's.     (Von  Esmarch  and  Kowalzig.) 


the  stomach,  while  the  upper  end  is  sutured  into  the  intestine  lower 
down  (Fig.  146).  This,  if  successful,  will  ensure  the  bile,  pancreatic 
juice  and  other  contents  of  the  intestine  being  delivered  into  the  intes- 
tine and  not  the  stomach.  But  it  will  be  seen  that  this  is  secured  at 
great  risks,  by  a  complicated  operation  involving  multiple  and.  prolonged 
suturing,  and  the  need  of  most  careful  adjustment  of  the  mesentery  at 
two  points. 

Kocher  having  noticed  fatal  cases  occurring  after  successful  suturing 
and  without  peritonitis,  a  fact  only  to  be  attributed  to  the  absorption  of 
intestinal  contents  which  have  reached  and  undergone  decomposition  in 
the  stomach,  unites  the  intestine  not  with  the  two  long  axes  correspond- 
ing, biTt  with  that  of  the  intestine  at  a  right  angle  to  that  of  the 
stomach,  and  in  such  a  way  that  the  proximal  fact  of  the  loop  ascends, 
and  the  distal  descends.  To  still  further  ensure  that  the  contents  of  the 
stomach  and  those  of  the  proximal  part  of  the  intestine  should  pass  out 
into  the  distal  portion  without  any  regurgitation,  Kocher  makes  a  valve 
by  raising  a  flap  from  the  convexity  of  the  knuckle  of  the  jejunum  at  a 
little  di^ance  from  the  stomach,  a  curved  incision  being  made  instead 
of  the  usual  longitudinal  one  (Figs.  147,  148).  The  con'tiguoiis  serous 
VOL.  IL  22 


338 


OPERATIONS  ON  THE  ABDOMEN. 


surfaces  of  stomach  and  jejunum  having  been  first  united,  the  outer 
surface  of  the  base  of  the  flap  is  next  united  to  the  lower  edge  of  the 
opening  in  the  stomach,  the  edge  of  the  flap  itself  being  left  free.  The 
upper  edge  of  the  opening  in  the  stomach  is  next  secured  to  the  lower 
and  concave  edge  of  the  opening  in  the  jejunum  (Fig.  148). 

After-treatment. — It  is  certain  that  surgeons  have  been  over-anxious 
with  regard  to  commencing  to  feed  their  patients  after  this  operation. 
After  careful  suturing,  or  indeed  after  any  of  the  methods  of  gastro- 
jejunostomy, feeding  by  the  mouth  should  be  carefully  begun  within  a 
few  hours  of  the  operation.  Such  licjuids  as  peptones,  Valentine's  meat 
juice,  raw  meat  juice,  champagne,  veal  tea,  brandv  and  water,  may  be 
given  in  teaspoonfuls  every  half-hour  at  first  and  soon  increased  up  to 
half-oiinces  every  hour. 

Sequelae  of  Gastro-jejunostomy. — (i)  In  the  cases  which  recover. 
(l)  In  many  great  relief  is  given  for  a  varying  number  of  months  from 
pain,  vomiting,  dyspepsia,  &c.,  while  a  gain  of  flesh  is  made  and  main- 


FiG.  147. 


Fig.  148. 


Gastro-jejunostomy  by  Kocher's  method.  The  jejunum  has  first  been  so  united 
to  the  stomach  as  to  prevent  kinking.  The  intestine  should  have  been  placed 
with  its  long  axis  at  a  right  angle  to  that  of  the  stomach.  (Von  Esmarch  and 
Kowalzig.) 


tained.  (2)  In  many  others  the  relief  is  much  more  short-lived  ;  the 
patient,  after  a  short  period  of  relief,  though  the  appetite  is  voracious, 
makes  no  flesh,  and  quickly  goes  downhill  again.  (3)  In  several 
cases  foetid  vomiting  has  set  in  soon  after  the  operation,  sometimes 
entirely  spoiling  the  result. 

(ii)  In  cases  ending  fatally. — The  causes  which  are  active  here  have 
been  sufiiciently  indicated  in  the  preceding  pages — viz.,  shock,  per- 
sistent vomiting,  peritonitis  (whether  due  to  sepsis  introduced  at  the 
time  of  the  operation,  or  to  leakage  later  on,  brought  about  by  some 
fault  in  the  technicpie),  and  recurrent  luemorrhage  from  some  of  the 
vessels  not  being  secured  by  ligature  or  by  the  sutures. 

Choice  of  Method. — So  conflicting  is  the  evidence  on  this  point  that 
it  cannot  be  said  at  the  present  time  which  is  the  best  method  to  employ. 
Persistent  vomiting  leading  to  death  from  inanition  is  a  not  uncommon 
sequel  to  the  operation,  and  it  is  to  avoid  this  that  the  various  modifica- 
tions of  the  operation  have  been  suggested.  The  vomiting  is  commonly 
due  to  one  of  two  causes — either  that  regurgitation  takes  place  from  the 
distal  loop  into  the  stomach,  or  that  the  opening  into  the  distal  loop  be- 
comes closed  owing  to  spur  formation  or  kinking.     Of  these  the  latter  is 


GASTKOPLTCATIOX.  339 

clearly  the  more  serious,  since  it  is  necessarily  fatal.  Chlumsky  (^Aiut. 
of  Surg.,  vol.  ii.  1898,  p.  285)  says  that  this  was  the  cause  of  death  in 
the  majority  of  the  fatal  cases  in  the  Breslau  clinic,  and  described  having 
found  the  distal  loop  completely  collapsed  and  empty  at  necropsies. 

With  regard,  first,  to  the  question  of  regurgitation,  the  claim  of  Von 
Hacker  that  the  posterior  operation  prevents  this  cannot  be  said  to  have 
been  proved,  although  published  results  tend  to  show  that  vomiting  from 
regurgitation  is  less  frequent  after  this  method,  and  certainly,  while  the 
patient  is  in  the  recumbent  position,  the  opening  is  more  favourable.  On 
the  other  hand,  the  greater  difiiculty  of  this  method  must  to  some  extent 
discount  the  advantage  gaiiied.  Regurgitation  can  doubtless  be  prevented 
by  some  of  the  more  complicated  proceedings  recently  introduced — 
such,  for  instance,  as  Wolfler's  second  method  (vide  Fig.  146) ;  but  here 
again  the  severity  of  the  operation  is  a  great  disadvantage.  With 
regard  to  the  best  method  of  preventing  spur  formation  and  blocking 
of  the  distal  loop  many  operators  are  in  favour  of  Murphy's  button. 
For  instance,  Chlumsky  (loc.  supra  cit.)  says  "the  opening  is  ideal  in  its 
working."  Kammerer  (loc.  supra  cit.)  is  of  the  same  opinion,  having 
had  eleven  cases,  with  a  satisfactory  opening  in  all  of  them,  also 
quoting  Carle  as  having  operated  upon  twenty-three  cases  without  a 
single  death,  and  Czerny  as  having  reduced  his  mortality  20  per  cent, 
by  the  use  of  Murphy's  button. 

On  the  other  hand.  Mayo  Robson,  Barker,  and  others  have  expressed 
contrary  opinions,  and  prefer  either  bobbins  or  suture.  If  Murphy's 
biitton  is  used  it  would  seem,  on  the  whole,  preferable  to  perform  the 
posterior  operation,  because  the  button  will  be  then  more  likely  to  pass 
into  the  intestine  than  to  drop  back  into  the  stomach. 

In  support  of  this  it  may  be  stated  that,  as  far  as  can  be  judged,  the 
results  of  this  plan — viz.,  posterior  gastro-jejnnostomy  with  Murphy's 
button — have  been  as  good  as  any  other  method. 


GASTROPLICATION. 

This  operation,  which  was  first  performed  by  Bircher  in  1891,  has  for 
its  object  the  reduction  of  the  size  of  a  dilated  stomach.  This  is  accom- 
plished by  making  one  or  more  longitudinal  folds  or  tucks  in  the  wall  of 
the  stomach  by  means  of  sutures.  The  operation  has  been  performed  a 
number  of  times.  Mayo  Robson  (Lancet,  March  24,  1900,  p.  831)  gives 
a  list  of  twenty-eight  cases,  with  two  deaths.  In  one  of  the  fatal  cases, 
however,  death  was  due  to  syncope  two  weeks  after  operation,  so  cannot 
be  ascribed  to  the  operation. 

Some  of  these  operations  were  performed  in  cases  in  which  definite 
pyloric  stenosis  was  the  cause  of  the  dilated  stomach.  It  is  clear  tliat 
such  a  proceeding  cannot  be  of  any  value  unless  the  pyloric  stenosis  is 
relieved  at  the  same  time  by  pyloroplasty  or  gastro-jejunostomy,  and 
even  then  the  propriety  of  gastroplication  is  doubtful,  since  there  is  a 
good  deal  of  evidence  to  show  that  a  dilated  stomach  quickly  recovers  its 
normal  size  after  removal  of  the  cause. 

The  application  of  gastroplication  therefore  should  be  limited  to  those 
very  rare  cases  of  idiopathic  dilatation  of  the  stomach.  .Even  in  these 
cases  the  question  of  gastro-jejunostomy  should  be  considered,  for,  as 


340  OPERATIONS  ON  THE  ABDOMEN. 

Farquhar  Curtis  (Ann.  of  Surg.,  July,  1900,  p.  49)  says,  "If  the  surgeon 
should  chance  to  overlook  some  cause  of  pyloric  obstruction  his  patient 
will  be  sure  of  a  cure  if  he  survives  the  operation,  whereas  gastroplication 
will  be  useless  if  pyloric  obstruction  exists." 


DUODENOSTOMY. 

This  and  the  following  operation  have  been  proposed,  in  cases  unsuited 
for  pylorectomy,  as  a  means  of  getting  nourishment  into  the  alimentary" 
canal  below  the  disease,  and  thus  giving  rest  to  the  diseased  parts, 
especially  in  those  cases  of  infiltration  of  the  whole  of  the  stomach, 
rendering  gastro-jejunostomy  impracticable.  But  little  favour  has'been 
accorded  to  either  of  these  operations,  and  both  are  destined  to  be 
dropped.  Duodenostomy  especially  has  the  serious  objections  that  it 
deals  with  a  fixed  portion  of  intestine,  one  difficult  to  deal  with,  and  one 
into^which  imjDortant  fluids  are  poured,  which  thus  may  readily  escape 
from  a  fistula  made  here.  Furthermore,  all  the  cases  have,  I  believe, 
been  fatal. 

JEJUNOSTOMY. 

This  operation  has  the  serious  disadvantage  of  being  liable  to  leakage 
at  a  point  high  up  in  the  alimentar}-  canal,  where  the  fluids  traversing 
the  bowel  are  of  the  greatest  importance  from  a  nutritive  point  of  xiew. 
Thus  it  has  followed  in  the  majority  of  cases  that  no  great  prolongation 
of  life  has  resulted  from  this  operation.  Dr.  Hahn  (JJeiit.  Med.  Wocli., 
1894)  gives  a  list  of  five  cases  of  jejunostomy.  One,  a  case  of  gastric 
carcinoma,  died  in  a  fortnight ;  another,  a  case  of  oesophagal  carcinoma, 
died  in  four  days  ;  the  third,  a  girl  aged  23,  who  five  weeks  before  had 
drunk  sulphuric  acid,  died  on  the  eighth  day.  Mr.  Jessett  {Dis.  of  the 
Stomach  and  Intestines,  p.  64)  relates  two  cases  operated  on  for 
oesophageal  carcinoma.  One  survived  nine  months,  when  extension  of 
the  disease  proved  fatal.  The  other  only  survived  seven  weeks.  Mr. 
Golding  Bird  brought  a  case  before  the  Clinical  Society  {Trans.,  vol.  xix. 
p.  70)  ;  here  the  operation  was  performed  for  advanced  carcinoma  of  the 
pylorus.  The  patient  was  making  a  good  recovery  up  to  the  ninth  day, 
when  fatal  peritonitis  occurred  owing  to  an  accident  in  the  feeding. 

Indications. — (i)  Cases  of  carcinoma  of  the  pjdorus  and  stomach 
where  other  operations  are  impossible.  (2)  Cases  of  carcinoma  of  the 
cardiac  end  of  the  stomach  and  oesophagus  when  gastrostomy  is  out  of 
the  question. 

Operation. — This  is  performed  Mith  strict  aseptic  precautions  and  in 
two  stages.  The  abdomen  having  been  opened,  the  jejunum  is  made 
certain  of  at  a  point  high  up  in  its  course  with  the  aid  of  the  directions 
given  at  p.  327.  A  kniickle  being  drawn  into  the  lower  part  of  the 
wound,  the  upper  two-thirds  of  this  are  united,  the  bowel  is  fixed  most 
carefullj'  to  the  edges  of  the  wound,  very  much  as  in  gastrostomy 
(p.  302).  The  intestine  should  be  opened  on  the  third  day  by  a 
small  puncture.  Later  on,  when  all  is  firm,  the  patient  will  be  able  to 
feed  himself  by  a  funnel  and  tubing.     If  it  is  absolutely  needful  to  open 


JEJUX0ST03IY.  .., 

it  at  once  the  surgeon  may  try  to  make  an  oblique  opening-  after  the 
method  ot  l\itzel  (p.  300).  Mr.  Golding  Bird  found  that  a  meal  of 
titteen  or  twenty  ounces  every  four  hours,  the  catheter  being  directed 
upwards,  always  caused  symptoms  due  to  over-distension  of  the  small 
mtestme,  and  that  a  better  plan  was  to  give  a  meal  of  ten  ounces  half 
being  given  towards  the  duodenum  and  half  towards  the  ileum 


CHAPTER   A'lII. 

EXCISION    OF    THE    SPLEEN. 

Indications. — All  of  these  are  rare,  and  many  of  them  are  still 
doubtful. 

1.  Cystic  Spleeit. — When  this  is  found  to  be  unsuited  for  drainage. 
Mr.  K.  Thornton's  case  of  this  kind  was  the  first  successful  splenectomy 
in  England. 

2.  Injunj. — This  has  been  already  alluded  to  when  gunshot  injuries  of 
the  abdomen  were  considered  (p.  285).  Other  cases  in  which  it  may  be 
called  for  are,  prolapse  of  a  spleen,  injured  or  not,  through  a  wound,, 
rupture  of  the  spleen,  and  stabs  of  this  viscus.  Hitherto  surgeons  have 
often  been  deterred  from  attempting  to  remove  a  ruptured  spleen  by  the 
frequency  with  which  this  injury  is  complicated  by  injury  to  other 
abdominal  or  thoracic  organs,  especiall}^  the  liver  itself.  From  the 
shock  of  these  the  i^atient  never  rallies  sufficiently  to  justify  exploration. 
Fresh  interest  will  be  called  to  this  matter  hj  three  successful  cases  of 
splenectomy  for  rupture  of  the  spleen  brought  b}-  Messrs.  Ballance 
and  Pitts  before  the  Clinical  Society  (Lancet,  vol.  i.  1896,  p.  484). 

Ill  the  first  case,  uuder  Mr.  Ballance,  a  boy,  aged  10,  had  been  struck  five  days  before 
his  admission  into  St.  Thomas's  Hospital  by  a  '•  f uU-pitched  ball"  on  the  left  side. 
Severe  pain  followed,  but  passed  ofE  until  a  few  hours  before  admission.  At  this  time 
severe  shock  was  present  from  which  the  patient  rallied  slightly.  The  spleen  was 
removed  through  a  four-inch  incision  in  the  left  linea  semilunaris.*  It  was  noticed 
that  a  speniculus  was  left  behind.  The  boy  recovered  rapidly,  and  was  in  robust 
health  five  mouths  later,  but  the  superficial  glands  had  enlarged. 

In  the  second  case,  also  under  Mr.  Ballance,  the  patient,  a  woman,  aged  45,  had  been 
run  over  by  a  hansom  cab.  Shock  was  so  marked  a  feature  that  operation  was  not 
justified  until  the  next  day.  Though  the  patient  left  the  theatre  in  a  desperate 
condition,  in  ten  days  she  was  apparently  convalescent.  Then  she  began  to  go  down- 
hill, and  by  the  eighteenth  day  her  condition  was  again  critical,  with  weakness, 
emaciation,  thirst,  drowsiness,  ice.  The  administration  of  extract  of  sheep's  spleen 
and  raw  bone  marrow  daily  restored  her  gradually  to  convalescence  and  ultimately  to 
complete  recovery.     Some  groups  of  external  lymphatic  glands  could  be  felt  in  this  case. 

In  the  third  case,  under  the  care  of  Mr.  Pitts,  a  man,  aged  36,  had  fallen  on  an  iron 
girder,   striking  his   left   side.     He   complained   of   pain   there,   but   was   otherwise 

*  In  one  at  least  of  these  three  cases  the  spleen  appears  to  have  been  removed  by  a 
median  incision.  This  would  have  the  advantage  of  allowing  the  operator  to  investigate 
the  state  of  the  liver  and  kidnevs. 


EXCISION  OF  THE  SPLEEX.  343 

apparently  well.  About  four  hours  later  ho  became  suddenly  collapsed.  Four  hours 
afterwards  he  had  responded  sufficiently  to  restoratives  to  make  operation  justifiable. 
This  patient,  when  apparently  convalescent,  began  to  lose  ground  in  a  similar  way 
to  the  second  patient.  Cod-liver  oil  and  bone  marrow  were  given,  but  it  was  not  till 
arsenic  was  administered  that  any  real  improvement  was  observed.  He  ultimately 
gained  robust  health,  but  all  the  superficial  lymphatic  glands  could  be  felt  enlarged. 

In  each  of  these  cases  the  spleen  was  not  only  ruptured,  in  the  third 
completel}^  across,  but  the  vessels  in  the  hilum  were  torn  across  also. 
The  authors  remarked  that  where  this  was  not  present  a  rupture  of 
moderate  severity  might  perhaps  be  treated  by  suture.  As  to  the 
diagnosis  of  ruptured  spleen  these  brilliant  successes  point  to  the  value 
of  the  following :  (a)  The  localitj^  of  the  injury ;  (6)  the  evidence  of 
internal  haemorrhage ;  (c)  the  great  increase  of  fixed  splenic  dulness  ; 
(d)  the  evidence  of  an  increasing  collection  of  fluid  in  the  abdomen,  and 
of  the  fact  that  while  the  dulness  in  the  right  flank  can  be  made  to  dis- 
appear by  change  of  position,  that  in  the  left  flank  remains  constant. 
The  operation  shovild  not  be  performed  until  the  patient  has  sufficiently 
reacted  from  the  stage  of  collapse,  and  it  should  take  place  before  that 
of  suppurating  clots  and  a  toxic  state  of  the  patient  has  supervened.  In 
the  case  of  the  spleen  where  an  escape  of  blood  alone  follows  on  the 
rupture,  the  last  mentioned  most  grave  condition  will  not  follow  so 
quickly  as  in  the  case  of  the  kidne}'.  The  peritongeal  sac  should  be 
cleaned  as  thoroughly  as  possible  from  all  blood  and  clots.  Every 
precaution  for  meeting  shock  should  be  taken  before  and  after  the 
operation. 

3.  MovaMe  or  Wandering  Sjjleen. — When  this  condition  causes 
troubles,  analogous  to  those  of  mov'able  kidney,  not  relieved  by  a  belt. 

Dr.  McGraw  QMed.  Hec,  vol.  xxxiii.  Xo.  26)  removed  an  enlarged  and  dislocated 
spleen,  which  formed  a  tumour  in  the  right  iliac  fossa,  and  partially  displaced  the 
uterus  and  bladder.  A  week  later  pain  in  the  left  shoulder  and  left-sided  pleuro- 
pneumonia supervened.  Nine  months  afterwards  the  ligature  was  coughed  up.  Ee- 
covery  followed. 

Operation  is  far  more  satisfactory  here  than  in  most  other  morbid  con- 
ditions of  the  spleen,  as  shown  by  the  statistics  of  the  last  decade  which 
are  given  by  Collins  Warren  [Ann.  of  /S'w>v/.,  vol.  i.  1901,  p.  521.) 
During  this  period  forty-three  cases  of  extirpation  of  wandering  spleen 
have  been  recorded  with  only  three  deaths. 

4.  Malvjnant  Disease. — Primary  sarcomatous  or  carcinomatous 
disease  of  the  spleen  is  extremely  rare.  Up  to  the  j^ear  1 890,  Ave  cases 
of  splenectomy  for  sarcoma  were  reported  by  Hagen,  of  which  three 
recovered  and  two  died.  From  1 891-1900  Warren  reports  five  further 
cases,  including  one  of  his  OAvn,  of  which  four  recovered  and  one  died. 

5.  Sjjlenic  Amemia. — This  condition  must  be  carefully  distinguished 
from  splenic  leukaemia.  The  latter  is  associated  with  marked  leucocy- 
tosis,  which  is  not  the  case  in  splenic  anoemia.  The  chief  symptoms  are 
splenic  hypertrophy,  gradually  increasing  anaemia,  and  a  tendency  to 
haemorrhages.  Collins  Warren  describes  a  case  in  which  the  disease 
was  cured  after  removal  of  the  spleen,  and  also  mentions  seven  cases 
reported  by  Sippy,  five  of  which  recovered  after  splenectomy 

6.  Malarial  Spleen. — With  regard  to  the  question  of  operation  for  this 
condition  Collins  Warren  says  :  '"  Quite  a  number  of  malarial  spleens  have 
been  removed  in  recent  years,  and  the  mortality  per  cent,  of  the  operation 


344  OPERATIONS  OX  THE  ABDOMEX. 

is  still  diminishing.  Hagen  has  collected  eighty-eight  cases  of  malarial 
hypertrophy  of  the  spleen,  exclusive  of  wandering  spleen.  Of  these 
cases,  twenty-four  previous  to  the  year  1890  gave  a  mortality  of  62*5 
per  cent.,  while  sixty- four  cases  operated  after  the  year  1890  gave  a 
mortality  of  2 3 -4  per  cent.  When  we  consider  the  very  large  size  that 
the  organ  often  attains  in  this  disease,  and  the  unfavourable  constitu- 
tional condition  of  the  patient,  such  results,  if  not  all  that  we  could  hope 
for  are  at  least  encouraging."' 

7.  Jjeul-cemia. — This  operation  has  been  so  invariably  fatal  that  it  ought 
to  be  aliandoned.* 

Operation. — The  preliminary  steps  will  be  directed  to  ensure  asepsis  and 
to  diminish  shock.  The  incision  has  usually  been  one  in  the  linea  alba. 
The  advantages  of  this  in  the  case  of  ruptm-ed  spleen  have  been  given 
above.  For  other  cases,  that  in  the  linea  semilunaris,  or  one  further  out 
(Bryant),  from  the  left  anterior  superior  spine  to  the  ribs,  would  probably 
give  better  command  over  the  pedicle.  Additional  room  may  be  gained 
by  division  of  the  left  rectus.  All  haemorrhage  having  been  stopped, 
the  peritonaeum  is  opened  freely  and  the  hand  explores  the  tumour.  If 
at  this  stage  the  surgeon  is  satisfied  that  the  adhesions  between  the 
spleen  and  the  diaphragm  are  extensive  and  intimate  he  will  do  well  to 
close  his  wound.  If.  however,  it  is  decided  to  proceed,  any  adhesions, 
as  of  the  overlying  omentum,  are  separated,  between  ligatures  if  needful. 
Where  the  adhesions  are  very  broad,  interlocking  chain-ligatures  must 
be  employed.  In  a  very  few  cases  the  use  of  the  thermo-cautery  may 
be  justified.  Any  adhesions  Avith  the  pancreas  are  xery  difficult  to  deal 
with.  Esmarch  and  Kowalzig  advise  removal  of  a  portion  of  this  viscus. 
The  spleen  is  next  brought  out  of  the  wound,  the  lower  extremity  first, 
and  sterile  gauze  is  carefully  packed  around  it.  This  extraction  of  the 
viscus  must  be  carried  on  with  the  utmost  caution  and  gentleness,  as  its 
friability  may  easily  lead  to  a  tear  and  most  profuse  oozing,  and  as 
dragging  on  the  pedicle  may  easily  induce  collapse,  and  is  also  likely  to 
lead  to  some  small  vessel  retracting  from  the  ligatures  as  they  are 
applied,  and  causing  fatal  haemorrhage. 

The  spleen  being  wholl}^  outside  the  body,  the  most  important  part  of 
the  operation,  securing  the  pedicle, remains.  Collins  Warren  findsthatthe 
remainder  of  the  operation  is  greatly  facilitated  if  the  spleen  is  at  this 
stage  rotated  forwards  so  that  the  posterior  surface  of  the  organ  is  in 
front.  A  better  view  of  the  pedicle  is  thus  obtained  withoiit  stretching, 
and  the  application  of  ligatures  is  therefore  rendered  easier.  The 
pedicle,  if  present,t  must  now  be  carefully  examined.  If  the  patient's 
condition  is  good,  the  safest  plan  will  be  to  secure  the  vessels  as  far  as 
possible  separately,  the  pedicle  being  divided,  as  the  late  Mr.  Greig 
Smith  suggested,  piecemeal  between  pressure-forceps ;  where  there  is 
not  time  for  this,  it  will  be  wiser  to  secure  the  vessels  in  two  or  three 
portions,  transfixing  in  two  places,  and  inter-locking  the  ligatures 
(Thornton).     Carbolised  silk  should  be  used,  fairly  stout,  and  not  tied 

*  The  late  Mr.  Greig  Smith  gave  eighteen  cases  ;  Mr.  Thornton,  thirteen  ;  Mr.  Collier, 
sixteen — all  fatal.  The  only  case  which  has  recovered — Franzolini's  of  Turin  (  Wie7i.  Med. 
Woch.,  1883,  No.  20) — is  considered  one  of  hypertrophy  by  Thornton,  Collier,  and  Credit. 

f  In  a  case  of  Mr.  L.  Browne's  (^Lancet,  vol.  ii.  1877,  p.  310)  there  was  no  pedicle  as 
such,  four  very  large  arteries  being  met  with  and  secured  with  double  ligatures. 


EXCISION  OF  THE   SPLEEX.  345 

so  tightly  that  it  will  cut  its  way  through  too  quickly.  However  the 
pedicle  is  treated,  the  following  precautions  should  be  followed  :  ( i)  To 
prevent  any  tension  being  exerted  on  the  pedicle  (vide  .-^uym).  (2)  To 
secure  every  vessel.  (3)  To  divide  these,  in  a  relaxed  condition,  at  a 
sufficient  distance  from  the  ligatures.  (4)  Xot  to  include  the  tail  of 
the  pancreas.  (5)  After  all  the  ligatures  have  been  applied,  it  may  be 
well  for  sake  of  safety  to  throw  one  round  the  whole.  (6)  Not  to  twist 
the  spleen  round  at  all  in  dealing  with  the  pedicle.*  In  some  cases 
where  secondary  haemorrhage  is  feared,  the  pedicle  should  be  kept  out- 
side. Again,  when  oozing  from  adhesions  is  veiy  likely  to  take  place, 
especially  when  a  large  gap  is  left  by  the  removal  of  a  huge  spleen, 
plugging  with  iodgform  gauze  after  the  method  of  !Mickulicz  will  be 
advisable  fp.  218). 

The  abdominal  sac  is  next  cleansed  and  the  operation  completed  as 
after  ovariotomy.     The  after-treatment  is  also  much  the  same. 

Causes  of  Death.. — By  far  the  most  frequent  is  haemorrhage.  This 
may  be  from  the  omentum  adherent  over  the  spleen,  from  the  large 
vessels  to  this  viscus.  from  some  small  vessel  which  has  retracted,  from 
the  splenic  vein,  or  from  sponge-like  adliesions  (Bryant). 

Mr.  Hatch,  of  Bombay  QLancet,  1889,  vol.  ii.  p.  1053).  met  vrith  a  case  in  which  death 
took  place  a  few  hours  after  the  splenectomy,  OAving  to  oozing  from  some  adhesions 
between  the  spleen  and  the  diaphragm,  which  had  required  separation.!  The  pedicle 
was  safely  secured.  In  another  case  QCentr.f.  Chir..  .July  18.  1885),  death,  twenty-four 
hours  after  the  operation,  was  due  to  bleeding  from  the  alxlominal  incision,  owing  to 
the  defective  coagulation  of  leuksemic  blood.     The  ligature  on  the  pedicle  was  firm. 

The  after-treatment  of  post-operative  anaemia.  cS:c..  is  given  at  p.  342. 

*  Sir  S.  Wells  (Med.  Times  and  Gaz.,  .Jan.  6,  1S66.  p.  4)  dia^ws  attention  to  this. 
Having  done  so  in  order  to  bring  the  vessels  into  a  cord,  the  splenic  vein  was  rupttired. 

t  See  also  G.  A.  Wright's  case  (J/i'rf.  Chron.,  Dec.  1888).  This  surgeon  suggests  the 
use  of  a  long,  sharply-curved  tenaculum  for  stopping  bleeding  from  a  deeply-seated 
vessel  in  the  back  of  the  abdomen. 


CHAPTER   IX. 

OPERATIONS   ON   THE  LIVER  AND   BILIARY 

TRACTS. 

OPERATIONS  ON"  THE  LIVER. 

HYDATIDS.— HEPATIC  ABSCESS.— REMOVAL  OF  GROWTHS 

OF  THE  LIVER. 

OPERATIONS   FOR   HYDATIDS. 

This  will  include  different  forms  of  puncture,  free  incision,  electrolj^sis. 
and  enucleation.  The  milder  measures  of  puncture  and  electrolysis 
have  proved  successful  in  many  cases,  but  we  do  not  know  for  certain 
how  the  death  of  the  parasite  is  brought  about  by  them  in  successful 
cases,  and  they  are  largel}'  uncertain. 

A.  Puncture. — While  incision  is  the  onh'  certain  and  reliable  mode 
of  cure,  it  is  worth  while  to  trj^  the  diflferent  forms  of  puncture,  espe- 
cially in  certain  cases,  for  instance  when  the  patient  refuses  severer 
methods. 

There  is  no  need  to  do  more  than  to  describe  briefly  such  an  operation 
as  this,  and  to  tabulate  the  chief  practical  points. 

The  parts  being  cleansed,  and  an  anesthetic  *  given  if  the  patient  is 
vevy  nervous,  the  surgeon  chooses  a  spot  for  puncture  at  a  most  promi- 
nent part  of  the  tumour,  satisfying  himself  as  to  dulness.f  If  the  skin 
is  thick  he  makes  a  minute  puncture  with  a  scalpel  and  sends  in  a  fine 
trocar  or  aspirator  needle.  The  quantity  withdrawn  must  varj"  with  the 
case,  the  size  of  the  cyst,  the  timidity  of  the  patient,  &c.  From  six  to 
sixty  ounces  are  instances  of  small  and  large  quantities.  The  aspirator 
should,  on  the  whole,  be  preferred,  as  likely  to  remove  more  fluid,  and 
thus,  probably,  more  likely  to  produce  a  cure,  but  as  the  exhaustion  is 
more  likely  to  pbig  the  cannula,  a  fine  wire  must  be  in   readiness. 

*  It  is  well  to  dispense  with  this,  if  possible,  from  the  possibility  of  leakage  taking 
place  during  the  subsequent  vomiting.  As  an  injection  of  cocaine  will  give  almost  as 
much  pain  as  the  fine  trocar,  the  part  may  be  frozen  with  the  chloride  of  ethyl  spray  if 
needful. 

f  If  this  is  presenting  against  the  right  ribs,  another  spot  should,  if  possible,  be 
chosen  (foot-note,  p.  349).  Hydatids  of  the  liver  should  never  be  explored  or  attacked 
through  the  ribs,  if  another  site  is  obtainable. 


OPERATIONS  FOll  IIVDATIDS.  347 

Dr.  Fagge  (Medicine,  vol.  ii.  p.  321;  thought  that  the  value  of  the 
aspirator  must  depend  entirely  on  the  position  of  the  hydatid.  If  a 
large  part  of  the  cyst  is  outside  the  liver  substance,  the  aspirator  may 
be  used  with  advantage ;  but  if  the  cyst  be  almost  entirely  buried  in 
the  liver,  Dr.  Fagge  thought  the  possible  suction  on  a  cyst  surrounded 
by  resistent  tissue  must  involve  some  risk  of  setting  up  inflammation. 
Escape  of  bile,  blood,  or  the  setting  up  of  a  cough  are  indications  for 
stopping.  While  the  cannula  is  withdrawn  the  sm^rounding  parts  should 
be  pressed  around  it,  and  rather  depressed,  so  as  to  diminish  the  risk  of 
leakage  as  the  cannula  leaves  the  cyst.  The  puncture  is  then  closed 
with  iodoform  and  collodion,  and  a  small  pad  of  dry  gauze  and  salicylic 
wool  comfortably  seciired  by  a  many-tailed  bandage.  A  little  morphia 
may  be  given  for  the  first  twenty-four  hours. 
Practical  Points. 

I.  Puncture  alone  is  more  likely  to  be  radically  curative  in  the 
following  cases : — A  small  cyst,  seen  early.  An  acephalocyst.  The 
more  daughter-cysts,  brood-capsules,  and  scolices  present,  the  less  likely 
it  is  that  puncture  will  suffice.  2.  Puncture  is  often  very  useful  as  a 
means  of  diagnosis  in  those  obscure  cases  in  which  hydatids  of  the 
liver  simulate  disease  of  the  pleura  or  lung.  3.  Incision  should  be  made 
use  of  where  tapping  fails,  where  scolices  instead  of  fluid  form  the 
greater  part  of  the  contents  of  the  cyst,  where  suppuration  is  present 
or  imminent,  and  where  chest  complications  are  set  up  by  the  hydatid, 
showing  perhaps  a  risk  of  perforation.  4.  A  few  weeks  after  puncture 
secondary  enlargement  is  often  noticed.  This  is  not  undesirable  as 
long  as  it  subsides,  which  it  usualh'  will  do  gradually,  being  due  to 
inflammation.  On  this  account  Dr.  Fagge  advised  that  no  second 
operation  on  a  hydatid  should  be  performed  within  twelve  months, 
unless  suppuration  is  present.  5.  Leakage  after  puncture  may  be 
shown  by  fluctuation,  more  or  less  distinct,  in  the  flanks.  The  result  of 
this  seems  to  have  been  variable.  In  some  cases  it  has  been  absolutely 
harmless,  as  in  a  case  of  electrolysis  of  mine  mentioned  below.  In 
others  it  has  been  as  certainly  followed  by  fatal  peritonitis.  6.  Cases 
of  hydatids  treated  by  puncture  should  be  watched  for  some  time  to 
make  certain  that  the  cure  is  a  sound  one.  7.  The  surroundings  of 
hydatids  of  the  liver  are  of  truly  vital  importance,  and  sudden  death 
has  followed  an  operation  more  than  once.  Thus,  in  Mr.  Bryant's  case 
(Clin.  80c.  Trans.,  vol.  xi.  p.  230),  while  a  hydatid  cyst  was  being- 
tapped,  the  portal  vein,  which  had  been  pushed  upwards  and  forwards 
by  the  projection  of  the  cyst  on  the  under-surface  of  the  liver,  was 
transfixed.  Death  followed  in  five  minutes,  and  was  thought  by  Dr. 
Fagge  to  be  due  to  hydatid  fluid  being  sucked  into  the  vein  as  the 
trocar  was  withdrawn. 

In  a  Russian  case  (Loiul.  Med.  Record,  1885,  p.  414)  the  pulse 
suddenly  stopped  while  the  cyst,  which  had  been  exposed  by  abdominal 
section,  was  being  stitched  to  the  incision.  At  the  necropsy,  a  crumpled 
echinococcus  had  made  its  wa}-  into  the  right  auricle,  and  a  fragment 
of  one  into  the  right  division  of  the  pulmonary  artery,  by  an  opening 
between  the  thinned  cyst  and  the  inferior  vena  cava.  Mr.  Willett 
(Brit.  Med.  Journ.,  Nov.  13,  1886)  mentioned  a  case  in  which  he  had 
to  aspirate  a  doubtful  swelling  of  the  liver.  He  used  an  ordinary-sized 
needle,  and  within  two  minutes  the  patient  was  dead.     It  turned  out 


348  OPERATIONS  ON  THE  ABDOMEN. 

to  be  a  case  of  malignant  disease.  No  large  vein  had  been  pricked, 
and  there  was  no  hasmorrhage.  The  sudden,  fatal  syncope  seemed  due 
to  the  impression  made  on  the  nervous  S3^stem  through  the  solar 
plexus. 

B.  Incision. — The  indications  for  this  in  preference  to  tapping  have 
been  given  above.  It  may  be  carried  out  in  one  or  two  stages.  The 
operation  is  thus  performed :  The  j^arts  being  cleansed  and  the  other 
preliminary  steps  taken,  the  surgeon  makes  an  incision  about  four 
inches  long  over  the  most  prominent  part  of  the  swelling  (previously 
carefully  percussed)  down  to  the  peritoneum.  This  incision  should,  if 
possible,  be  made  in  front.  Even  if  a  cyst  or  abscess  shows  its  greatest 
point  of  prominence  through  the  ribs,  it  should  not  be  opened  here 
unless  it  is  quite  certain  that  the  pleural  space  is  obliterated ;  moreover, 
the  large  drainage-tube  needful  necessitates  resection  of  a  portion  of  a 
rib.  All  hasmorrhage  is  next  arrested,  and  the  above  layer  carefully 
divided  and  sutured  to  the  subcutaneous  tissue  in  the  edges  of  the 
wound  with  a  few  points  of  chromic  gut.  The  liver  is  now  recognised, 
and  iodoform  or  sterile  gauze  tampons  are  carefully  packed  in  on  either 
side  so  as  to  prevent  any  escape  of  fluid  into  the  periton£eal  sac. 

The  needle  of  an  aspirator  or  a  fine  trocar  is  then  thrust  in,  and  the 
existence  of  fluid  beneath  thus  verified.  As  the  needle  is  withdrawn 
the  liver  is  incised,  and  a  finger  quickly  plugs,  and  then  enlax'ges  to  an 
inch  and  a  half,  the  opening  made  by  the  knife.  Haemorrhage,  if  free, 
is  easily  arrested  thus,  or  by  sponge-pressure.  Escape  of  fluids  into  the 
peritoneal  sac  is  prevented  by  the  use  of  the  tampons  already  men- 
tioned, by  an  assistant  keeping  the  edges  of  the  wound  carefully 
adjusted  to  the  liver,  and,  lastly,  b}^  the  next  step,  which  consists  in 
hooking  up  the  opening  in  the  liver  with  the  finger,  and  in  stitching 
the  edges  of  the  wound  in  the  liver  to  that  in  the  abdomen  with  a 
continuous  suture  of  chromic  gut.  While  inserting  this,  care  must  be 
taken  to  unite  peritoneeum  to  peritona3um,  and  to  take  up  a  suflSciency 
of  liver-tissue  b}^  inserting  the  needle  well  away  from  the  edges  of  the 
wound.  As  the  sutures  are  inserted  the  tampons,  &c.,  must  be  gradually 
withdrawn,  and,  if  the  fluid  escapes  very  freely,  it  may  be  well  to  turn 
the  patient  over  on  one  side.  Any  scolices  which  are  within  reach  are 
next  removed,  and,  if  the  cyst  is  firmly  stitched  and  the  patient's  con- 
dition good,  the  contents  and  wall  of  the  hydatid  may  be  cleared  out 
with  sponges  on  holders,  aided  by  scoops.  All  handling  must  be  of  the 
gentlest.  A  large  drainage-tube  is  then  inserted,  and  the  usual  gauze 
dressings  applied. 

Operation  by  Ttco  Stages. — An  incision,  four  inches  long,  is  made 
through  the  abdominal  wall  over  the  most  prominent  part  of  the  swell- 
ing. All  bleeding  having  been  carefully  stopped,  the  peritonaeum  is 
picked  up  and  slit  open.  The  liver,  recognisable  by  its  characteristic 
colour,  is  at  once  seen  moving  with  respiration.  To  make  certain  of 
the  position  of  the  fluid,  a  fine  trocar  may  be  now  thrust  in.  If  the 
cyst  be  crammed  with  scolices,  very  little  fluid  escapes;  if  it  be  an 
acephalocyst,  the  fluid  may  spirt  out  under  the  high  joressure  not 
infrequently  met  with.  After  a  few  ounces  have  been  withdrawn,  any 
leaking  is  stoi:)ped  b}^  sponge  pressure,  the  parietal  peritoneum  is 
stitched  to  the  edges  of  the  wound  by  a  few  points  of  chromic  gut 
suture,  the  wound  plugged  with  strips  of  iodoform  gauze  wrung  out 


OPEKATIOXS  FOR  HYDATIDS.  349 

of  carbolic  acid  (i  in  20),  and  the  dressings  firmly  bandaged  oia  with 
a  good  deal  of  pressure  so  as  to  keep  the  abdominal  wall  as  far  as 
possible  in  contact  with  the  liver.*  On  the  third  day  the  operation 
is  completed  by  incising  the  liver,  now  well  adherent,  and  inserting 
a  large  draining-tube.  I  have  operated  by  both  methods  on  patients 
of  my  colleagues  Dr.  Pye-Smith,  Dr.  F.  Taylor,  and  Dr.  Xewton  Pitt. 
All  the  cases  did  well,  though  in  two  the  complete  filling  up  of  the 
cavity  was  very  tedious.  One,  a  woman,  three  months  pregnant  at  the 
time  of  the  operation,  went  her  full  time  subsequently. 

C.  Electrolysis. — This  mode  of  treatment  was  used  by  Dr.  Fagge 
and  Mr.  Durham  in  eight  cases,  and  the  results  brought  before  the 
Medico- Chirurgical  Society  (Trans.,  vol.  liv.  p.  i).  The  modus  operandi 
here  is  uncertain,  as  in  puncture,  but  it  seems  probable  that  neither  the 
electrolytic  action  nor  the  leakage  of  fluid  into  the  peritonaeal  sac,  but 
the  puncture  alone  of  the  needle,  is  the  essential  element.  Thus,  in  a 
case  of  Dr.  Playfair's,  related  in  the  appendix  to  Dr.  Fagge's  paper, 
progressive  diminution,  almost  identical  to  that  noticed  after  electrolysis, 
followed  acupuncture  only.  This  being  so,  and  the  method  requiring* 
special  instruments,  it  has,  1  believe,  fallen  into  abeyance.  In  one  case, 
a  patient  of  Dr.  Moxon's,  I  made  use  of  this  method  after  previous 
tapping  had  failed.  The  steps  taken  by  Dr.  Fagge  and  Mr.  Durham 
were  carefully  followed.  Two  electrol\i;ic  needles  were  passed  into  the 
most  prominent  part  of  the  swelling,  about  two  inches  apart,  and  were 
then  attached  to  wires  both  connected  with  the  negative  pole  of  a 
galvanic  battery  of  ten  cells.  A  moistened  sponge  connected  with  the 
positive  pole  was  placed  on  the  skin  at  a  little  distance.  The  current 
was  passed  for  half  an  hour.  The  punctures  were  then  closed  with  a 
pad  of  gauze.  Indistinct  fluctuation  could  be  made  out  in  the  flanks 
during  the  next  forty-eight  hours.  There  was  no  constitutional  dis- 
turbance, the  tumour  steadily  diminished  in  size,  and  a  good  recovery 
took  place.     But  I  lost  sight  of  the  patient  afterwards. 

D.  Enucleation. — A  number  of  cases  in  which  the  cyst  has  been 
enucleated  from  the  liver  have  now  been  reported,  and  the  success  met 
with  has  been  considerable.  Thus  Posadas  (Bevue  de  Chirurgie,  March, 
1899,  p.  374)  reports  twenty-three  cases,  of  which  nineteen  recovered, 
and  four  died. 

The  tumour  is  exposed  by  a  free  incision,  and  isolated  from  the  rest 
of  the  peritona?al  cavity  by  means  of  tampons  of  iodoform  gauze.  After 
being  emptied  the  whole  cyst  is  enucleated  from  the  liver,  the  incision 
in  the  latter  then  closed  by  means  of  sutures,  and  the  abdominal  incision 
sutured  without  drainage.  This  operation  is  clearly  much  more  severe 
than  incision  and  drainage,  and  moreover  the  mortality  (over  17  per 
cent.)  is  very  much  too  high.  It  should,  therefore,  not  be  performed 
except  under  ver}'  sJDCcial  circumstances,  e.<j.,  when  the  cyst  is  small  and 
partially  pedunculated. 


*  One  case  bulged,  out  the  right  lower  ribs  most  markedly.  For  reasons  already 
given,  I  preferred  to  attack  it  in  the  front  of  the  right  hvpochondrium.  On  exposing 
the  liver,  a  hydrocele  trocar  passed  through  an  inch  and  a  half  of  hepatic  tissue 
before  fluid  was  reached.  Very  little  hsemorrhage  followed  the  completion  of  the 
second  stage  of  the  operation. 


350  OPERATIONS  OX  THE  ABDOMEN. 

HEPATIC    ABSCESS.— HEPATOTOMY.* 

Tapping  by  a  trocar,  and  draining  the  abscess  by  the  cannula  left  in, 
or  a  drainage-tube  passed  through  the  cannula,  the  latter  being  then 
withdrawn,  is  unsatisfactor}",  for  the  following  reasons: — (i)  The 
cannula  and  tube  may  slip  out.  (2)  The  drainage  is  inefficient. 
(3)  If  the  pus  leaks  into  the  peritoneal  sac,  it  does  so  unseen.  (4)  The 
trocar  may  puncture  important  parts.  Thus,  in  one  case  of  Mr.  K. 
Thornton's  (Med.  Times  and  Gaz.,  1883,  vol.  i.  p.  89),  the  omentum, 
containing  large  veins,  lay  over  the  liver.  (5)  Puncture  and  drainage 
would  be  quite  insufficient  in  cases  where  more  than  one  abscess  existed. 
It  is  to  a  free  incision,  therefore,  that  we  must  look  for  a  permanent 
cure.     This  may  be  employed  in  three  ways : 

I.  Direct  incision  and  drainage,  when  tenderness,  oedema,  and 
redness  make  it  probable  that  adhesions  exist.  This  needs  no  further 
comment.  2.  Incision  and  drainage  by  abdominal  section  in  two 
stages.     3.  Incision  and  drainage  by  abdominal  section  at  one  sitting. 

The  methods  of  treating  an  hepatic  abscess  by  abdominal  section, 
whether  in  one  or  two  stages,  have  already  been  spoken  of  at  p.  348, 
under  the  heading  of  Hydatids.  They  have  the  following  advantages 
over  other  modes  of  treatment : — [a)  The  benefit  of  a  free  incision  and 
thorough  drainage  ;  (li)  the  surgeon  can  see  what  structures  he  is 
dealing  with;  (c)  bleeding  from  the  liver  can  be  seen  and  arrested; 
(cl)  if  pus  escapes  into  the  peritonteal  sac,  this  can  be  cleansed. 

Very  little  need  be  said  here  of  the  treatment  by  abdominal  section 
in  additioTi  to  that  alread}"  written  at  p.  348.  In  the  two-stage  method 
the  surgeon  will  open  the  peritoneeal  sac,  suture  the  parietal  peritonseum 
to  the  edges  of  the  wound,  insert  some  gauze,  and  endeavour,  by  well- 
adjusted  bandaging,  to  keep  the  abdominal  parietes  in  contact  with  the 
liver,  opening  the  abscess  on  or  after  the  third  day. 

In  the  method  by  direct  incision,  a  free  incision  of  four  or  five  inches 
is  made  and  the  parietal  peritonaeum  united  to  the  subcutaneous  tissues 
of  the  wound.  The  position  of  the  pus  having  been  verified  by  a  fine 
trocar  or  aspirator  needle,  tampons  of  iodoform  gauze  ai-e  carefully 
packed  around.  The  abscess  is  then  incised,  and  the  opening  at  once 
plugged,  and  freely  dilated  with  the  finger.  Any  escape  of  pus  into  the 
peritoneeal  sac  is  prevented  ( i )  by  the  careful  packing  ;  (2)  by  the  finger 
hooking  up  the  liver  against  the  wound ;  (3)  by  an  assistant  keeping 
the  parietes  steadily  against  the  liver.  Haemorrhage  is  controlled  by 
forceps  or  sponge-pressure.  When  the  abscess  is  emptyf  its  opening  is 
plugged  with  a  sponge,  and  the  liver  and  the  parietes  being  still  kept 
accuratel}^  together,  the  tampons  first  inserted  are  removed,  and  the 
edges  of  the  liver  wound  stitched,  with  carbolised  silk  passed  with 
curved  needles  on  a  holder,  to  the  edges  of  the  abdominal  incision,  care 
being  taken  to  keep  peritonseal  surfaces  well  in  contact.  If  the  pus  is 
foetid  the  abscess  cavity  should  be  Avell  irrigated  with  a  dilute  antiseptic 

*  This  term  is  also  applicable  to  incision  of  the  liver  for  hydatids. 

f  The  late  Mr.  Greig  Smith  (Abdom.  Surg.,  p.  527)  advised  that,  if  the  abscess  does  not 
empty  itself  readily,  a  large  tube  lying  in  carbolic  lotion  may  be  pinched  at  the  end,  and 
when  placed  at  the  bottom  of  the  abscess  will  act  as  a  syphon.  He  also  draws  atten- 
tion to  the  need  of  exploring  the  abscess  cavity  for  signs  of  a  second  abscess,  and,  if 
this  be  fonud,  opening  it  with  the  finger  or  dressing-forceps.  All  manipulations  noAv 
must  be  of  the  gentlest  for  fear  of  haemorrhage. 


HEPATIC  ABSCESS.— HEPATOTOMY.  35 1 

lotion.  A  considerable  thickness  of  dry  gauze  dressings  will  be  needed 
at  first,  and  will  require  frequent  renewal.  This  will  be  facilitated  by 
the  use  of  a  many-tailed  bandage. 

Treatment  of  Cases  of  Hydatid  or  Abscess  of  the  Liver  which 
have  opened,  or  which  threaten  to  open,  into  the  Chest. — I  refer 
here  to  those  grave  and  difficult  cases  where  a  hydatid  C3"st  or  hepatic 
abscess,  instead  of  making  its  way  towards  the  abdominal  wall,  works 
upwards,  thrusting  up  the  base  of  the  lung.  Perhaps  the  first  few 
tappings  have  drawn  off  fluid  from  the  front,  but  after  this  the  cyst 
recedes  from  the  epigastric  region  as  in  Mr.  Owen's  case  (loc.  infra  cit.). 
In  other  and  rare  cases  the  C3^st  or  abscess  has  been  opened  from  the 
front  or  the  side  through  the  abdomen,  but  insufficient  drainage  is  thus 
given.  In  such  cases  the  advice  given  on  p.  348  must  be  set  aside,  and 
the  fluid  must  be  drained  through  the  pleux*a.* 

Mr.  Godlee  sutured  the  diaphragmatic  and  costal  layers  of  pleura 
round  the  edge  of  an  aperture,  made  by  removing  a  portion  of  rib.  and 
then  opened  an  hepatic  abscess.  Mr.  Thornton,  treating  a  similar 
affection  with  a  view  of  obtaining  a  funnel  through  the  pleura,  along 
which  the  pus  could  escape  safely,  first  raised  the  parietal  pleura  all 
round,  so  as  to  get  a  little  free  edge,  then  made  a  very  careful  longi- 
tudinal incision  through  the  visceral  pleura,  raised  it  all  round,  and  then 
with  a  fine  curved  needle  united  the  two  layers  with  a  continuous  fine 
silk  suture.  A  channel  being  thus  made,  the  liver-abscess  was  opened 
by  a  curved  trocar,  the  puncture  converted  into  an  incision,  and  a  large 
drainage-tube  inserted.  Mr.  Owen,  in  the  case  of  a  hydatid  c^^st  which 
encroached  upon  the  thorax,  incised  the  eighth  intercostal  space,  first 
behind  the  anterior  axillary  line.  As  soon  as  the  costal  pleura  was  divided, 
air  rushed  freely  in  with  a  very  audible  sound,  and,  the  finger  being  in- 
troduced, the  diaphragm  was  at  once  felt  bulging  up  along  the  inner 
surface  of  the  ribs,  while  the  lung  had  retired  loeyond  reach.  The 
intercostal  space,  which  was  fairl_v  roomy,  was  forcibly  widened,  but  it 
was  not  thought  necessary-  to  excise  a  piece  of  rib.  The  phrenic  pleura 
and  the  diaphragm  were  then  carefully  incised,  and  the  abdominal  cyst 
was  discovered.  A  certain  amount  of  its  contents  were  withdrawn  by 
aspiration,  so  as  to  relieve  its  tension,  and  to  permit  of  some  of  the  face 
of  the  sac  being  drawn  through  the  diaphragm,  and  across  the  shallow 
pleural  cavity  to  the  skin  wound,  to  which  it  was  secured  by  four  hare- 
lip pins.  The  serous  surfaces  thus  placed  in  contact  were  found  firmly 
adherent  on  the  fourth  day.  An  incision  was  then  made  into  the  cyst, 
and  a  drainage-tube  inserted.     All  three  patients  recovered. 

REMOVAL    OP    PORTIONS    OF    THE    LIVER    FOR    NEW 

GROWTHS. 

This  operation  will  always  remain  a  rare  one  from  the  infrequency  of 
growths  which  admit  of  removal.  Keen  {Ann.  of  Stirg.,  Sept.  1899, 
p,  267)  has,  however,  collected  no  less  than  seventy-four  cases,  in  an 
important  paper  from  which  most  of  what  follows  has  been  gathered. 
The  mortality  has  so  far  been  only  14-9  per  cent.,  so  that  the  risk  of  the 

*  Mr.  Godlee  (^Brit.  Med.  Jtmrn.,  1887,  vol.  ii.  p.  872),  Mr.  K.  Thornton  {ihid.  1886, 
vol.  ii.),  Mr.  Owen  (^Clln.  Sr.c.  Trans.,  vol.  xxi,  p.  78),  and  others  have  successfully 
adopted  this  course. 


352  OPERATIONS  ON  THE  ABDOMEN. 

operation  is  certainly  not  a  very  serious  one.  Some  idea  of  the  variety  of 
tumours  that  have  been  removed  from  the  liver  may  be  obtained  from 
the  following  list  •which  Keen  gives  : — Constricted,  accessory,  or  her- 
niated left  lobe,  five  cases  ;  syphiloma,  tv^elve  cases  ;  carcinoma,  seven- 
teen cases ;  adenoma,  seven  cases ;  sarcoma,  five  cases ;  angioma,  four 
cases ;  cavernoma,  one  case ;  cystoma,  one  case ;  angio-fibroma,  one 
case ;  small  calculi,  one  case ;  endothelioma,  one  case ;  h3'datid  cysts, 
twenty  cases. 

The  chief  difficulty  met  with  is  hgemorrhage  ;  this  has,  however,  been 
satisfactorily  controlled,  either  by  isolating  the  tumour  b)"  means  of  an 
elastic  ligature  before  removal,  or  by  dividing  the  liver-substance  with 
the  cautery,  and  li gating  any  large  vessels  met  with  while  this  is  being- 
done.  Keen  removed  a  carcinomatous  left  lobe  weighing  one  pound 
and  five  ounces  in  a  man  aged  50,  by  the  latter  method,  which  he 
describes  as  follows  : — 

"  The  operation  ^^'as  done  entirely  with  the  Paquelin  cauterj".  It 
took  from  twenty  to  thirtj^  minutes  to  sever  the  left  lobe  from  the 
remainder  of  the  liver.  The  haemorrhage  was  not  very  severe,  except- 
ing when  I  burned  into  some  of  the  larger  veins.  Each  of  these,  when 
opened,  I  was  able  instantly  to  close  by  my  left  forefinger.  Then,  tem- 
porarily laying  aside  the  cautery,  I  passed  a  catgut  ligature  under  each 
by  means  of  a  Hagedorn  needle,  and  one  of  my  assistants  tied  it  slowlj' 
but  firmly.  Five  ligatures  were  thus  applied.  Three  of  the  veins 
required  ligatures  of  both  of  the  divided  ends.  The  hgemorrhage,  except 
from  these  large  veins,  was  arrested  by  the  Paquelin  cautery,  except 
that  occasionally,  when  I  laid  aside  the  cautery  to  apply  a  ligature, 
temporary  packing  with  iodoform  gauze  was  of  great  service  in  arrest- 
ing the  parenchymatoiTS  hasmorrhage."  The  cavity  left  was  partially 
occluded  by  means  of  sutures,  the  remainder  being  loosely  packed  with 
gauze.     Complete  recovery  took  place. 

In  other  cases  the  charred  surfaces  after  suturing  have  been  treated 
without  drainage  without  any  untoward  result. 

When  the  elastic  ligature  is  employed,  long  steel  pins  are  so  placed 
as  to  prevent  the  ligature  from  slipping,  and  the  tumour  then  removed 
half  an  inch  beyond  the  ligature.  The  wound  is  then  closed  round  the 
stump,  which  must  be  carefully  kept  aseptic.  In  a  case  treated  success- 
fully in  this  wa}^  by  Mayo  Robson,  the  pedicle  left  was  as  thick  as  the 
wrist,  and  after  the  separation  of  the  slough  a  granulating  surface  was 
left.     This  gradually  contracted,  and  the  patient  made  a  good  recovery. 

OPERATIONS  ON  THE  BILIARY  TRACTS  :  CHOLECYSTOS- 
TOMY  —  CHOLECYSTOTOMY  —  CHOLELITHOTRITY  — 
CHOLEDOCHOTOMY  —  CHOLECYSTENTEROSTOMY  — 
CHOLECYSTECTOMY  —  TREATMENT  OF  BILIARY 
FISTULA. 

As  the  indications  for  these  operations  are  nearly  always  gall-stones 
or  their  complications,  it  will  be  well  first  to  briefly  consider  the  dif- 
ferent sites  in  which  biliar}^  calculi  are  met  with  and  the  chief  evidence 
by  which  the}^  may  be  differentiated,  it  being  alwaj'S  understood  that, 
as  several  of  the  following  conditions  may  coexist,  the  symptoms  to 
which  a  grouj)  of  gall-stones  in  one  position  gives  rise  often  runs  into 


OPERATIONS   OX  THE  BILIARY  TRACTS.  353 

those  of  another,  (i)  The  calculus  or  calculi  are  in  the  fjoM-hladder.  The 
symptoms  here  will  be  chiefly  recurrent  attacks  of  colic,  associated  with 
local  tenderness  and  often  with  pyrexia.  No  swelling  may  be  present 
unless  a  calculus  exists  lower  down,  and  for  the  same  reasons  there  will 
be  no  jaundice,  (ii)  The  stone  or  stones  are  in  the  cystic  duct.  Here 
there  will  be  colic,  and  presence  of  a  swelling  having  the  characters  of 
a  distended  gall-bladder.  Jaundice  is  as  a  rule  absent,  but  if  a  calculus 
in  the  cystic  duct  makes  pressure  on  the  common  hepatic  duct  this 
point  of  guidance  will  be  lost,  (iii)  The  calculus,  one  or  more,  occupies 
the  common  duct.  This,  according  to  the  duration  of  the  mischief,  will 
be  more  or  less  dilated,  and  the  same  applies  to  the  tracts  behind,  unless 
other  calculi  are  present  here.  In  addition  to  colic,  jaundice  will  be 
present,  and  if  adhesions  are  forming,  if  any  ulceration  and  septic  process 
is  going  on,  pj-rexia  may  be  present  also.  The  gall-bladder,  as  pointed 
out  by  Mr.  Terrier,  Mr.  Mayo  Robson,  and  others,  is  usually  contracted, 
shrunken,  and  matted  down  by  adhesions  in  these  cases,  so  that  no 
tumour  will  be  present.  Should  distension  of  the  gall-bladder  be  present 
in  association  with  the  symptoms  mentioned  above,  it  is  to  be  looked 
upon  as  pointing  rather  to  malignant  disease  than  to  the  presence  of 
gall-stones.  Other  points  which  may  help  in  deciding  between  these 
two  conditions  are  the  time  the  trouble  has  lasted,  the  persistency  of 
jaundice,  and  the  age  and  general  condition  of  the  patient. 

Mr.  Mayo  Robson  {Med.  Ann.  1898)  points  out  that  calculi  are  more 
often  situated  in  the  common  bile-duct  than  has  been  hitherto  sup- 
posed, having  found  this  condition  in  20  per  cent,  of  two  hundred 
operations  performed  for  gall-stones.  The  same  author  also  draws 
attention  to  the  ver}^  important  fact  that  multiple  calculi  in  the 
common  duct  are  more  fi^equent  than  solitar}^  ones. 

In  addition  to  the  above  it  must  be  remembered  that  gall-stones  are 
generally  associated  with  inflammatory  complicatious,  which  vary 
greatly,  both  as  regards  the  parts  involved  and  the  intensity  of  the 
process.  Even  in  the  most  simple  cases  some  degree  of  adhesion  from 
local  peritonitis  will  be  present,  and  in  the  more  complicated  cases  the 
difficulties  that  the  operator  may  have  to  face  may  be  extreme.  Some 
of  these  will  be  referred  to  later  in  the  accounts  of  the  various  opera- 
tions. The  following  may  be  mentioned  as  some  of  the  special  compli- 
cations of  gall-stones  that  may  call  for  surgical  intervention  : — Empyema 
of  the  gall-bladder,  abscess  around  the  gall-bladder  or  bile-ducts,  sup- 
purative cholangitis,  chronic  catarrhal  inflammation  of  the  gall-bladder 
and  bile-ducts,  and  phlegmonous  cholecystitis. 

An  operation  for  gall-stones  is  usually,  in  the  first  instance,  under- 
taken for  exploratory  purposes,  the  special  operation  which  is  called  for 
being  then  undertaken,  according  to  the  conditions  found  to  be  present. 
The  steps  of  the  exploration  will  therefore  be  first  described,  and  the 
details  of  the  separate  operations  given  subsequently. 

As  a  prophylactic  against  the  troublesome  haemorrhage  which  is 
liable  to  attend  operations  upon  patients  suffering  from  jaundice,  Mayo 
Robson  (Diseases  of  the  Gall-Madder  and  Bile-dticts)  recommends  the 
administration  of  chloride  of  calcium.  He  prescribes  thirty-grain 
doses  every  four  hours  for  a  few  daj's  before  operation,  and  continues 
the  administration  for  some  time  after  the  operation,  giving  it  either  by 
the  mouth  or  per  rectum. 

VOL.  II.  23 


354  OPERATIONS  ON  THE  ABDOMEN. 

Operation. — In  order  to  render  the  parts  more  accessible,  Mayo 
Robson  (loc.  supra  cit.)  places  a  firm,  narrow  sand-bag  under  the 
patient's  back  at  the  level  of  the  liver.  This  brings  the  common  duct 
two  to  three  inches  nearer  to  the  surface,  and  also  tends  to  open  out  the 
costal  angle,  and  displace  the  intestines  downwards  away  from  the 
liver. 

The  anaesthetic  will  usually  be  the  A.C.E.  mixture  or  chloroform, 
ether  being  unsuited  to  many  of  these  patients,  often  middle-aged  and 
stout  and  flabby,  and  the  subjects  of  chronic  bronchitis.  The  abdomen 
having  been  cleansed,  one  of  the  following  incisions  is  made  use  of : — 
(i)  A  vertical  one,  over  the  prominence  of  any  swelling  present,  or 
straight  down  from  the  tip  of  the  cartilage  of  the  tenth  rib.  It  should 
be  four  inches  long  to  begin  with,  and  should  be  prolonged  down  to  the 
level  of  the  umbilicus  if  more  room  is  wanted  for  the  exploration  of  the 
common  duct.  This  incision,  if  the  wound  be  widely  retracted,  will 
answer  in  nearly  all  cases.  Where  the  adhesions  are  very  difficult  to 
deal  with,  more  room  may  be  got  by  adding  to  it  a  transverse  incision 
carried  inwards  along  the  margin  of  the  ribs  at  its  upper  extremity. 
Another  very  useful  incision  which  is  alwaj^s  employed  by  some  operators, 
and  which  is  excellently  suited  for  those  cases  where  much  difficult}^  is 
expected,  is  a  transverse  or  curvilinear  one,  starting  a  little  below  the  tip 
of  the  ninth  rib,  at  the  outer  edge  of  the  rectus,  and  passing  in  a  trans- 
verse or  curvilinear  direction  into  the  loin  ;  if  extra  room  is  needed  it 
may  be  carried  as  far  as  the  outer  edge  of  the  quadra tus  lumborum.* 
Either  of  the  above  incisions  will  give  better  access  than  one  in  the 
linea  semilunaris  or  linea  alba.  The  second  one  gives  the  best  access  of 
all,  but  we  must  wait  for  the  results  of  cases  which  have  been  adequately 
watched  before  we  can  accept  as  certain  the  statement  that  the  trans- 
verse incision  is  no  more  likely  to  be  followed  by  a  ventral  hernia  than 
is  the  vertical  one,  because  it  is  in  the  upper  and  firmer  part  of  the 
abdominal  wall.  The  peritonseum  having  been  reached,  any  vessels 
which  need  it  are  secured  with  chromic  gut.  The  peritonaeum  is  next 
picked  up  and  opened.  The  gall-bladder  and  bile-ducts  are  then  care- 
fully explored,  and  a  decision  come  to  as  to  the  further  measures  that 
will  be  necessary. 

CHOLECYSTOSTOMY. 

If  the  gall-bladder  is  distended  and  free  from  adhesions,  it  is  isolated 
by  means  of  iodoform  or  sterile  gauze,  then  aspirated  and  opened. 

If,  on  the  other  hand,  the  gall-bladder  is  small  and  shrunken  and 
imbedded  in  adhesions,  these  must  now  be  dealt  with.  The  difficulties 
met  with  here  ma}^  be  due  merely  to  omentum  or  distended  intestines 

*  This  incision  is  recommended  by  Mr.  R.  Morison,  of  Ne\vcastle-on-Tyne  (-l^m.  nf 
SiiTf].,  August,  1895,  p.  181).  He  gives  the  credit  of  it  to  Dr.  John  Duncan,  of  Edin- 
burgh. Besides  the  excellent  access  which  the  incision  gives,  there  is  another  advan- 
tage which  will  be  given  when  the  subject  of  drainage  is  considered.  This  incision  is 
practically  the  same  as  Courvoisier's,  much  used  on  the  Continent  and  in  America — 
viz.,  an  incision  about  ten  inches  long,  running  obliquely  parallel  to  the  lower  border 
of  the  right  ribs,  and  about  half  an  inch  below  thcra,  with  its  centre  lying  over  any 
swelling  that  is  present. 


CHOLEC  YSTOSTOMY.  355 

concealing  the  gall-bladder,  or  adhesions  may  have  taken  place  about 
this  structure  to  a  varying  degree.  The  following  case  of  Mr.  Robson's 
is  a  good  instance  of  the  difficulties  which  may  be  met  with  : 

The  tumour  on  being  exposed  '-seemed  to  be  composed  of  liver,  gall-bladder, 
etomach,  and  omentum  matted  together.  No  fluctuation  could  be  made  out,  and  the 
tumour  seemed  so  firm,  hard,  and  nodulated  as  to  give  the  impression  of  being  malig- 
nant. An  exploring  syringe  pushed  deeply  into  the  swelling  simply  withdrew  a  little 
blood !  but  on  pushing  the  needle  through  the  overlapping  edge  of  the  liver,  in  the 
direction  of  the  cystic  duct,  pus  was  withdrawn.  On  attempting  to  separate  the  liver 
from  what  was  supposed  to  be  the  gall-bladder,  pus  began  to  well  up,  but  fortunately 
none  of  it  escaped  into  the  peritonseal  cavity,  as  sponges  had  been  packed  round  the 
opening.  On  dilating  the  opening  sufficiently  to  admit  the  finger,  gall-stones  were  at 
once  felt,  one  of  which,  about  the  size  of  a  small  walnut,  was  easily  removed;  the 
second,  impacted  in  the  cystic  duct,  broke  in  removal,  leaving  the  distal  portion  still 
within  the  duct ;  this  was  removed  with  considerable  difficulty,  as,  on  account  of  the 
matting  of  the  parts,  the  finger  could  not  be  passed  beyond  the  cystic  duct  to  aid  in 
its  expulsion ;  after  its  removal  the  index  finger,  on  being  pushed  into  the  duct  as  far 
as  possible,  discovered  another  impacted  stone,  which  it  was  found  impossible  to 
remove.  As  the  sequel  showed,  this  was  perhaps  rather  a  happy  circumstance,  for,  on 
account  of  the  depth,  the  friability,  and  the  adhesions  of  the  gall-bladder,  it  was 
found  impossible  to  suture  it  to  the  surface,  as  the  stitches  would  not  hold ;  hence, 
after  the  suppurating  cavity  had  been  washed  out  with  a  solution  of  fluosilicate  of 
soda  (gr.  x. — Oj)  and  a  drainage-tube  inserted,  the  upper  and  lower  ends  of  the 
incision  were  drawn  together  by  silk  sutures  so  as  to  somewhat  limit  the  opening. 
The  peritonaeal  cavity  was  left  freely  open,  two  sponges  being  placed  on  each  side  the 
opening  into  the  gall-bladder  so  as  to  absorb  any  discharge  flowing  out  of  it.  They 
were  at  first  changed  every  two  hours,  antiseptic  precautions  being  adopted.  At  the 
«nd  of  two  days  they  were  removed,  one  being  simply  applied  directly  over  the 
drainage-tube,  so  as  to  press  the  parietal  peritonaeum  into  contact  with  the  visceral." 

The  patient  made  a  complete  recovery. 

In  some  cases  the  gall-bladder  may  be  actually  buried  in  adhesions, 
involving  such  structures  as  the  abdominal  wall,  omentum,  duodenum, 
and  pylorus.  The  liver  must  be  pushed  up  and  the  intestines  held  aside 
with  iodoform  gauze  tampons,  so  arranged  as  to  shut  off  the  general 
peritongeal  sac.  The  adhesions  are  then  most  carefully  separated  with 
a  fine  blunt  dissector  (Fig.  92),  a  steel  director,  or  curved  scissors, 
bleeding,  chiefly  troublesome  oozing  from  adhesions,  being  checked  by 
ligature  or  by  firm  pressure  with  gauze.  While  this  is  being  effected 
the  operator  must  be  prepared  in  some  cases  for  an  escape  of  jdus,  which 
has  been  shut  in  by  these  adhesions,  outside  the  gall-bladder  or  the 
ducts  lower  down.  In  one  case  of  Mr.  Thornton's  {Brit.  Med.  Journ., 
1886,  vol.  ii.  p.  902),  the  majority  of  the  stones — 412  were  removed — 
lay  in  a  cavity  in  the  liver  substance.  Through  the  liver-tissue 
which  presented  in  the  incision  stones  could  be  felt  moving  on  each 
other :  the  gall-bladder  was  small  and  atrophied  ;  a  large  stone  occupied 
the  common  duct.  Here  the  large  stone  originally  in  the  gall-bladder 
had  become  impacted  in  the  common  duct,  the  other  stones  being 
formed  in  the  hepatic  duct  and  above  it  in  the  liver,  where  they 
gradually  hollowed  out  a  cavity. 

The  gall-bladder  having  been  found  and  freed  from  adhesions,  is 
brought  into  the  wound  if  possible,  and  having  been  isolated  by  means 
of  gauze  tampons,  it  is  first  emptied  by  aspiration ;  the  puncture  is 
then  enlarged,  and  a  forefinger  inserted  to  feel  for  calculi.  If  it  is  clear 
that  an}^  present  will  be  difficult  of  removal,  the  edges  of  the  opened 


356 


OPERATIONS  OX  THE  ABD03IEN. 


gall-bladder  should  be  sutured  to  the  margins  of  the  wound  by  a  con- 
tinuous suture  of  sterilised  silk,  or  by  interrupted  ones  at  short 
intervals.  The  parietal  peritongeum  must  be  carefully  taken  up,  and 
the  sutures  passed  at  a  sufficient  distance  from  the  edges  of  the  gall- 
bladder and  the  incision  in  the  abdominal  wall  to  ensure  a  good  hold.  The 
sutures  should  pass  through  any  bleeding  points  in  the  cut  gall-bladder, 
and,  as  they  are  inserted,  the  sponges  or  tampons  should  be  withdrawn. 
Mr.  Mayo  liobson  Qoc.  supra  cit.)  strongly  advises  the  following  method 
of  suturing  the  gall-bladder  as  likely  to  prevent  a  permanent  fistula  : 
The  serous  coat  of  the  gall-bladder  is  sutured  to  the  parietal  perito- 
naeum, and  the  mucous  coat  to  the  aponeurotic  layer  of  the  abdominal 
wall,  thus  leaving  the  skin  and  subcutaneous  tissue  free  to  granulate 
and  close  the  opening. 

The  gall-bladder  having  been  thus  safely  steadied  prior  to  any 
manipulations  which  may  be  needful — and  the  extraction  of  a  stone 
fixed  low  down  in  the  cystic  duct  is  often  a  prolonged  affair — any 
calculi  which  lie  near  the  surface  are  removed  \\i\\\  scoops  (Fig.  149)^ 


Fig. 


149. 


Lawson's  Tait's  scoop  for  gallstones.     (Down's  Catalogue.) 

dressing-forceps,  or  the  forceps  shown  in  Figs.  1 50  and  151.  Of  these  I 
have  found  the  one  to  the  left  of  Fig.  151,  though  its  blades  appear 
somewhat  clumsy,  very  efficient  in  extracting  stones  when  the  ducts  are 
dilated.  Where  a  stone  impacted  low  down  in  the  cystic  duct  resists 
all  efforts  at  extraction  from  the  gall-bladder  by  scoops  or  forceps, 
attempts  must  be  made  to  push  it  up  into  the  gall-bladder  by  a  finger 

FiG.  150. 


Anderson's  forceps  for  the  extraction  of  gallstones.  As  the  blades  unlock, 
either  can  be  introduced  separately,  and  then  used  as  a  probe  or  scoop.  In  a 
difficult  case  these  forceps  are  very  helpful.     (Down's  Catalogue.) 

introduced  into  the  abdomen  through  the  lower  part  of  the  wound. 
This,  after  the  gall-bladder  has  been  secured  by  sutures,  is  left  open — 
kept  plugged  with  iodoform  gauze  or  a  carbolised  sponge — so  that  a 
finger  can  be  introduced  from  time  to  time  to  assist  an}"  instrument 
working  from  the  gall-bladder,  or  to  dislodge  any  calculus  out  of  the 
cystic  duct.  If  all  attempts  at  removal  or  dislodgment  fail,  the  calculus 
must  be  treated  by  cholelithotrity,  choledochotomy,  or  cholecystenteros- 
tomy  (vide  infra). 

In  some  instances  it  will  not  be  possible  to  bring  the  gall-bladder  up 
to  the  abdominal  incision  and  suture  it  there.  Maj'^o  Robson  meets 
this  difficulty  as  follows.  He  says,  "It  has  at  times  been  possible  to 
tuck  down  the  parietal  peritonscum  to  the  edges  of  the  gall-bladder 


CHOLECYSTOSTOMY. 


357 


opening,  and  so  to  effect  suture  of  the  contiguous  margins  ;  but  in 
several  cases  where  this  could  not  be  done  the  right  border  of  the  omen- 
tum has  been  sutured  to  the  margin  of  the  gall-bladder  opening  and  to 


Fig.   151. 


Tail's  cholelithotomy  forcejjs.     (Greig  Smith.) 

the  parietal  peritoneeum,  thus  forming  a  tube  of  peritonaeum  around 
the  drainage-tube,  and  shutting  out  the  general  pferitonseal  cavity-" 
If  neither  of  these  plans  is  available,  a  tube  should  be  placed  in  the 

Fig.  IS2. 


gall-bladder  and  surrounded  with  gauze  packing.     This  will   be  found 
quite  efficient  in  preventing  leakage  into  the  peritonaeal  cavity. 

Murphy's    Drainage-tube    Button    (Fig.   1^2). — This,  is    a    modifi- 
cation of  the   inventor's  well-known  anastomosis  button,  in  which  the 


358  OPERATIONS  OX  THE  ABDOMEN. 

female  half  is  elongated  to  form  a  drainage-tube,  so  as  to  reach  from  the 
deep-seated  gall-bladder  to  the  surface.  The  following  is  the  way  in 
which  it  is  used  :  "The  gall-bladder  is  located,  a  sufficient  surface  of  its 
wall  exposed,  the  contents  aspirated,  the  purse-string  suture  (Fig.  103, 
p.  269)  inserted,  the  gall-bladder  is  incised,  the  small  half  of  button 
inserted,  purse-string  tied  and  cut  short,  the  tubular  portion  of  the 
button  is  then  pressed  into  position,  the  tube  is  then  drawn  out  as  far  as 
the  gall-bladder  will  permit,  and  held  there  with  a  pin  passed  through 
the  opening  in  its  side.  During  the  time  that  the  pressure  atrophy  in 
the  portion  of  the  gall-bladder  clasped  between  the  button  is  taking- 
place,  a  cicatricial  wall  is  being  formed  about  the  tube  which  acts  as  the 
wall  of  a  sinus  after  its  production,  and  insures  continued  protection  of 
the  peritonaeal  cavity." 

The  following  criticism  is  by  an  American  surgeon,  Dr.  Binnie  (loc. 
supra  cit.)  :  "  This  operation  is  extremely  ingenious,  but  in  many  cases, 
especially  those  in  which  its  use  would  otherwise  help  us  most,  it  is  in- 
applicable. If  the  gall-bladder  is  deeply  seated,  and  its  walls  friable,  the 
introduction  of  the  purse-string  suture  would  be  difficult  or  impossible. 
If  the  gall-bladder  is  very  small  and  shrunken,  it  cannot  contain  the 
male  half  of  the  button.  If  the  opening  is  in  the  duct,  the  button 
operation  is  generally  out  of  the  question.  For  these  reasons  the 
Murphy  operation  must  be  of  very  limited  utility." 

This  operation  has  been  performed  m  two  star/es,  as  in  opening  a 
hepatic  abscess  (p.  350),  but  this  is  c[uite  needless  here,  unless  the 
anesthetic  should  be  taken  badly  or  some  other  quite  unforeseen 
complication  occur. 

CHOLECYSTOTOMY. 

Here  the  gall-bladder  is  sutured  at  once  after  the  extraction  of  the 
stones,  e.g.,  with  a  continuous  suture  of  the  mucous  membrane,  and 
then  a  row  of  Lembert's  sutures,  and  returned  into  the  peritongeal  sac. 
This  step  has  two  grave  objections,  (i)  It  is  not  so  safe  as  cholecystos- 
tom}",  owing  to  the  risk  of  leakage  if  the  walls  of  the  gall-bladder  are 
at  all  inflamed  and  softened.  This  is  just  an  instance  of  an  operation 
where  we  hear  of  the  successful,  but  never  of  the  unsuccessfiTl  cases. 
(2)  It  is  very  difficult  to  be  certain  that  all  the  ducts  are  patent.  If  a 
stone  be  left  behind,  suturing  and  returning  the  gall-bladder  will  give 
rise,  in  the  immediate  future,  to  dangerous  tension  on  the  sutures  by 
the  back-flow  of  the  bile,  while  it  prevents,  later  on.  any  attempts  being 
renewed  through  the  open  gall-bladder. 


CHOLELITHOTRITY 

The  term  has  been  applied  to  crushing  a  gall-stone  inside  one  of  the 
ducts.  The  method  was  first  adopted  b}^  Lawson  Tait,  \^'ho  made  use  of 
forceps  in  order  to  crush  the  stone.  This  j^lan,  however,  is  not  to  be 
recommended,  owing  to  the  danger  of  injuring  the  wall  of  the  duct. 
Mayo  Robson  (loc.  supra  cit.)  crushes  the  stone  by  pressure  between  the 
thumb  and  finger,  and  reports  thirty-one  cases  in  which  he  has  adopted 
this  plan  without  any  subsecjuent  trouble  from  damage  to  the  ducts. 


CIIOLEDOCHOTOMY.  359 

In  the  case  of  the  common  duct,  the  left  forefinger  is  passed  through 
the  foramen  of  Winslow  behind  the  stone,  and  the  thumb  is  placed  in 
front  of  it.  Pressure  first  produces  flattening  of  the  stone ;  but  on  chang- 
ing the  position  of  the  fingers  so  that  the  edges  of  the  flattened  stone 
are  pressed  together,  fracture  into  a  number  of  small  pieces  usually 
takes  place.  These  are  then  pressed  on  into  the  duodenum  or  washed 
through. 

Stones  which  are  too  hard  to  be  crushed  in  this  wa}"  should  be 
removed  by  choledochotomj^,  unless  the  condition  of  the  patient  forbids 
an3"thing  further  being  done.  In  this  case  the  action  of  solvents 
applied  through  the  cholecystostomy  wound  must  be  tried. 

Impacted  stones  have  also  been  broken  up  b}"  means  of  a  needle 
passed  through  the  wall  of  the  duct.  Mayo  Robson  and  others  have 
come  to  the  conclusion  that  this  method  is  unadvisable  on  account 
of  unavoidable  damage  to  the  ducts. 

The  chief  objection  to  cholelithotrity  is  the  difiiculty  of  completely 
clearing  the  ducts  of  debris.  On  this  account  cholecystostomy  should 
be  performed  at  the  same  time,  and  the  ducts  thoroughly  syringed 
through  with  warm  sterile  water. 


CHOLEDOCHOTOMY. 

This  term  has  been  given  to  the  operation  of  removing  stones  from 
the  biliary  ducts  by  direct  incision.  This  method  has  gained  ground 
very  much  of  late  years.  Its  safety  in  careful  and  competent  hands 
has  been  established,  and  it  has  been  proved  that  stones  impacted  deep 
in  the  cystic  or  in  the  common  duct,  which  otherwise  must  have  been 
left  behind  as  persistent  sources  of  misery  or  as  causes  of  an  open 
biliar}'  fistula,  extraction  by  opening  the  gall-bladder  or  cholelithotrity 
having  proved  impossible,  can  now  be  safely  removed. 

While  the  important  relations  of  these  ducts — especially  the 
common — must  always  be  remembered,  the  presence  of  the  stone 
itself  forms  a  reliable  guide,  as  long  as  the  incision  is  made  directly 
over  it. 

We  will  take  the  operation  for  removal  of  a  calculus  from  the 
common  duct.  The  incision  in  the  abdominal  wall  beino-  lenatheued 
if  necessary  so  as  to  give  satisfactory  exposure  of  the  parts  concerned, 
the  liver  is  held  up,  the  edges  of  the  wound  are  held  widely  open,  rmd 
the  position  of  the  stone  accurately  defined.  One  of  the  retractors 
shown  in  Figs.  153  and  154  may  here  be  found  useful  in  keeping  back 
the  intestines.  The  area  of  operation  is  then  carefully  shut  off  by 
iodoform  gauze  packing  and  sponges  secured  to  forceps,  and  any 
adhesions  over  the  stone  are  very  carefulh'  separated  while  the 
duodenum  is  drawn  down  or  turned  aside.  The  stone,  firmly  held, 
is  raised  as  high  as  possible.  The  incision  is  not  to  be  made  until 
the  surgeon  feels  certain  that  he  is  directly  over  the  stone.  The 
escape  of  bile,  which  is  very  profuse  if  it  has  been  long  pent  up 
or  if  the  blocked  duct  is  dilated,  must  be  met  by  assiduous  sponging 
or  washing  away  with  boiled  water. 

After  removal  of  the  main  stone  the  ducts  must  be  thoroughly 
and    systematically    explored ;    for   as    has    already   been    pointed   out 


36o 


OPERATIONS  ON  THE  ABDOMEN. 


there  are  usually  several  stones  present,  and  the  failure  to  remove 
them  all  will  render  the  operation  useless.  This  exploration  should 
be  carried  out  with  the  finger  if  the  ducts  are  sufficiently  dilated,  or 
failing  this  by  a  bent  j^robe  or  small  scoop.  The  finger,  however, 
should  be   employed  wherever  possible,  because   it  is  the  only  really 

Fig.  153. 


St.  Thomas's  Hospital  intestine  retractor. 


certain  method.  Mayo  liobson  strongly  emphasises  this  point,  and 
mentions  a  case  in  which  a  probe  and  scoop  failed  to  discover  a 
stone  which  was  found  afterwards  on  digital  examination. 

The  ducts  having  been  cleared,  it  remains  to  consider  the  different 

Fig.  154 


Maunsell's  intestine  guard. 

means  of  treating  the  opening  in  the  duct.  If  the  passages  above  and 
below  are  patent,  if  the  opening  is  accessible,  and  if  the  patient's 
condition  admits  of  further  prolonging  of  the  operation,  sutures  should 
certainly  be   employed  for  the  additional  security  which  they  give.* 


*  Even  if  the  sutures  do  not  hold,  they  do  good  by  preventing  or  lessening  the 
escape  of  bile  while  adhesions  are  forming  to  shut  off  the  peritonseal  sac. 


CIIOLEDOCIIOTOM  Y.  3  6 1 

The  escape  of  bile  being  prevented  by  the  pressure  of  the  fingers  above 
the  opening,  the  incision  by  which  the  stone  has  been  extracted  is 
closed  by  a  continuous  suture  of  chromic  gut  for  the  duct  itself,  while 
a  second  set  of  sutures  of  silk  are  used  to  draw  together  the  cut  edges 
of  the  overlying  peritongeum.  The  sutures  are  best  inserted  by  a  small 
fully-curved  needle  held  in  pressure-forceps,  by  Mr.  W.  A.  Lane's  cleft 
palate  needles  held  in  his  special  needle-holder  (vide  Fig.  197,  vol.  i.), 
or,  as  recommended  by  Mr.  M.  Kobson,  by  a  rectangular  cleft-palate 
needle.  The  value  of  a  free  incision,  opening  up  the  ^^•ound  in  every 
direction,  pulling  up  the  liver,  drawing  down  the  duodenum  and  colon, 
and,  perhaps,  the  use  of  an  electric  lamp,  will  be  very  apparent  now. 
The  assistants  must  be  assiduous  with  well-applied  sponge-pressure. 
In  the  words  of  Dr.  Binnie,  of  Kansas  City  (Ann.  of  Surg.,  Nov. 
1894,  p.  563):  "A  difficulty  which  occasionally  confronts  the  surgeon 
is  to  distinguish  at  the  bottom  of  a  deep  and  narrow  pit  the  wounded 
duct  from  oozing  adhesions  recently  divided." 


Fig.   155. 


[T 


Halsted's  Haminei'. 

Mr.  Halsted  (John  Hopkins  Hosp.  Bull.  April  1898)  recommends 
the  use  of  a  small  metal  hammer  in  order  to  facilitate  the  introduction 
of  sutures.  The  head  of  the  hammer  is  made  in  a  variety  of  sizes  and 
is  fitted  with  a  long  slender  handle  (Fig.  155).  The  hammer  chosen 
should  be  large  enough  to  fully  distend  the  duct.  The  head  of  the 
hammer  is  passed  through  the  incision  in  the  duct  and  serves  to  steady 
the  latter  and  also  to  lift  it  up  towards  the  surface  while  the  sutures 
are  passed.     The  hammer  is  then  removed  and  the  sutures  tied. 

Where  the  opening  cannot  be  sutured,  the  surgeon  will  use  either 
some  of  the  adjacent  soft  parts  to  act  as  a  dam  between  the  duct  and 
surface,  and  so  prevent  the  bile  from  entering  the  peritonseal  sac,  or 
he  will  employ  drainage  and  iodoform  gauze.  Amongst  the  soft  parts 
that  are  handy,  the  omentum  at  once  presents  itself  as  the  most 
available.  Mr.  Mitchell  Banks  {Liverpool  Med.-Chir.  Journ.,  1893,  p. 
307)  in  a  case  of  cholecystostomy,  in  which  the  incision  in  the  gall- 
bladder could  not  be  united  to  that  in  the  abdominal  wall,  made  use  of 
"  the  round  ligament  of  the  liver  and  some  neighbouring  omentum, 
which  he  fastened  to  the  gall-bladder  and  succeeded  in  so  banking  it  up 
as  to  prevent  the  bile  from  flowing  into  the  peritoneeal  cavit3\"  Binnie. 
of  Kansas  City  (loc.  supra  cit),  made  use  of  separated  adhesions,  after 
extracting  a  calculus  through  the  opened  cystic  duct. 

"Suture  of  the  wounds  in  the  bladder  and  the  duct  might  have  been  possible,  but 
as  it  would  certainly  have  taken  much  time  I  decided  to  drain,  but  at  the  same  time 
to  build  up.  of  omentum,  mesentery  and  existing  adhesions,  a  diaphragm  between  the 


362 


OPERATIONS  ON  THE  ABDOMEN. 


track  of  the  drain  and  the  general  peritonasal  cavity.  Thus  the  wounded  biliary 
passages  were  left  open,  a  few  stitches  of  catgut,  judiciously  placed,  bound  together 
the  various  structures  above  mentioned  in  such  a  way  that  in  a  few  hours  they  became 
an  impervious  rampart  of  adhesions.  ...  A  rubber  drain  was  also  passed  to  the 
bottom  of  the  wound,  and  surrounded  throughout  its  whole  length  with  a  liberal 
supply  of  iodoform  gauze." 

Drainage. — It  will  be  safer  to  always  use  this  in  some  form  or  other* 
whenever  the  ducts  have  been  incised,  bu.t  with  more  elaborate  pre- 
cautions, of  course,  when  no  sutures  have  been  inserted.  To  take  the 
latter  case  first.  A  curved  glass  tube,t  with  the  end  turned  upwards, 
should  always  be  inserted  if  possible  into  the  opening  in  the  duct — an 
easy  matter  when  these  are  much  dilated.  It  should  then  be  carefully 
packed  around  in  its  whole  length  with  iodoform  gauze.  The  readiness 
with  which  this  forms  adhesions,  leading  to  bleeding  and  difficulty  in 

detaching  it,  is  well  known 
Fif*-  156.  to  those  who  have  used  it 

in  abdominal  surgery. 

Dr.  K.  Abbe,  of  New  York, 
recommends  the  method  of 
drainage  shown  in  Fig.  1 56, 
which  he  has  used  success- 
fully (loc.  supra  .  cit.).  A 
stone  having  been  removed 
from  the  common  duct, 
a  large  drainage-tube  was 
passed  into  the  hepatic  duct 
through  the  opening  in  the 
common  duct,  this  opening- 
being  then  sewn  up  with 
fine  silk.  Around  the  tube 
which  emptied  the  hepatic 
duct  a  larger  one^  was 
placed,  reaching  to  the 
common  junction,  and  a  light  iodoform  tampon  was  finally  pushed  in. 
All  the  bile  came  through  the  tube  for  five  days  ;  the  inner  one  was 
removed  on  the  second  day,  and  the  sinus  closed  in  three  weeks,  the 
patient  making  an  excellent  recover}^. 

Where  the  opening  has  been  closed  with  sutures  it  will  still  be  wise 
to  use  a  drainage-tube  for  a  day  or  two,  the  indication  for  this  being 
clearer  in  cases  where  the  suturing  has  been  attended  with  difficulty, 
where  the  edges  of  the  duct  are  much  bruised,  and  where  any  con- 
traction may  exist  in  the  biliary  passage  below. 


Abbe's  method  of  suture  and 
drainage.  A  drainage-tube  has 
been  placed  in  the  hepatic  duel ; 
an  opening  in  the  common  duct 
is  sutured.  The  gall-bladder  has 
been  removed.  This  fact  is  not 
shown. 


\ 


/ 


*  It  has  been  stated  that  drainage  is  not  needed  as  pure  bile  does  not  excite 
peritonitis.  I  am  of  opinion  that  the  surgeon  can  rarely  tell  for  certain  whether 
the  bile  is  pure  or  not.  Certainly  in  cases  where  there  have  been  repeated  attacks  of 
cholelithiasis  with  pyrexia  it  is  extremely  probable  that  the  bile  is  infected  from  the 
intestines — e.g.,  with  the  bacillus  coll  communis.  And  this  is  the  more  likely  when  any 
part  of  the  ducts  has  been  long  dilated  into  a  large  sac. 

t  If  the  flow  of  bile  is  profuse,  syphonage  (p.  383)  may  be  adopted,  rubber  tubing 
being  attached  to  the  glass  tube. 

:J:  If  glass  tubes  are  used  care  must  be  taken  that  the  end  is  not  jammed  against 
the  structures  with  which  it  is  in  contact,  otherwise  ulceration  may  readily  follow. 


CHOLEDOCIIOTOMY.  363 

If  any  bile  has  escaped  into  the  peritongeal  sac — a  rai'e  contingency 
if  the  gauze  packing  has  been  careful — there  are  two  places  where  it 
may  be  well  to  insert  a  drainage-tube.  One,  if  the  flow  has  been  very 
free,  is  in  Douglas's  pouch  by  an  incision  above  the  pubes ;  this  will 
be  seldom  required.  The  second  and  more  suitable  spot  is  one  to 
which  Mr.  Morison,  of  Newcastle,  has  drawn  attention  (Brit.  Med. 
Journ.,  vol.  ii.  1894,  p.  968).  He  there  shows  that  in  the  right 
hypochondrium,  between  the  liver  and  the  colon,  is  a  natural  space 
with  barriers  which  separate  it,  more  or  less  completely,  from  the 
general  sac.  Bile  may  be  allowed  to  escape  into  this  space,  as  long 
as  it  is  efiiciently  drained  by  an  incision  made  through  the  posterior 
parietes  immediately  below  the  lower  end  of  the  right  kidney.  If  the 
curved  incision  which  Mr.  Morison  and  others  recommend  (p.  354)  be 
made  use  of,  the  drainage-tube  will  be  in  the  lower  and  outer  angle 
of  the  wound. 

Before  leaving  the  subject  of  extraction  of  stone  from  the  biliary 
passage  it  remains  to  refer  to  one  lodged  so  far  down  in  the  common 
duct  as  to  be  practically  immediately  outside  the  duodenum.  As  might 
be  expected,  such  stones  are  very  difficult  to  identify.  The  peritonasal 
sac  having  been  opened,  any  omentum  adherent  to  the  abdominal  wall 
or  the  neighbourhood  of  the  liver  must  be  separated,  other  adhesions 
carefully  divided,  and  the  gall-bladder  identified,  if  possible.,  as  a  guide. 
The  pylorus,  duodenum,  and  transverse  colon  must  also  be  identified  and 
drawn  to  the  left  downwards.  The  liver  nmst  be  kept  well  up  out  of 
the  wa}'  \\dth  retractors  or  the  fingers  of  an  assistant.  The  identifica- 
tion of  the  common  duct  will  now  vary  in  difficulty  according  as  its 
relations  are  natural  or  matted  by  adhesions.  If  the  former  is  the  case, 
the  stone  being  exactly  taken  as  a  guide,  a  vertical  incision  is  made 
through  any  fold  of  peritoneeum  passing  down  to  or  in  front  of  the 
mesocolon,  including  the  mesocolon.  The  vertical  incision  is  deepened 
with  a  blunt  dissector  or  tlie  finger  until  the  head  of  the  pancreas  is 
exposed  and  the  deeper  surface  of  the  duodenum,  including  the  whole 
length  of  the  common  duct.  This  will  be  facilitated  by  pulling  the 
duodenum  well  over  to  the  middle  line.  The  importance  of  working- 
most  carefully  just  over  the  stone  is  sho^^^l  by  the  relations  of  the  com- 
mon duct:  '"This  receiving  the  cystic  and  hepatic  ducts  about  two 
inches  below  the  liver  in  the  beginning  of  its  course  lies  directly  in  front 
of  the  portal  vein.  Below,  before  it  enters  the  duodenum,  it  crosses  the 
inferior  vena  cava.  Its  orifice  admits  the  passage  of  a  probe  or  director 
pretty  easily."     (Richardson.) 

Anofher  proof  of  the  importance  of  the  relations  of  the  common  duct,  is  shown  by 
the  fact  that  even  in  Mr.  Mayo  Eobson's  experienced  hands,  ftecal  extravasation  took 
place  from  a  small  perforation  iu  the  colon,  caused  by  the  separating  adhesions  during 
the  removal  of  a  stone  from  the  common  duct,  the  injury  being  unrecognised  at  the 
time.  Another  instructive  case  is  that  of  Eoss  (^Canadian  Practitioner,  April,  1894). 
Here  several  stones  were  lodged  in  the  common  duct,  the  duodenum  was  accidentally 
torn,  and  this  opening  was  enlarged  in  the  hope  of  reaching  the  stones  through  the 
opening  in  the  duct,  but  this  point  could  not  be  found.  The  common  duct  was  accord- 
ingly opened  and  the  stones  removed.  The  duct  was  sutured,  but  owing  to  the 
friability  of  the  tissues  at  the  site  of  the  roughened  stone,  it  was  impossible  to  prevent 
the  leakage  of  bile.  Drainage  was  employed  with  iodoform  gauze.  The  bile  continued 
to  flow,  but  increased  suddenly  after  vomiting,  and  the  case  ended  fatallj^  fifty-six 
hours  after  the  operation. 


364  OPERATIONS  ON  THE  ABDOMEN. 

The  site  of  the  stone  having  been  reached  with  certainty,*  the  follow- 
ing methods  are  open  to  the  surgeon  :  (i)  Pushing  it  into  the  intestine, 
or  upwards  into  a  more  accessible  position.  If  this  fail,  a  trial  may  be 
made  of  breaking  up  the  stone  with  the  finger  and  thumb.  (2)  The 
duct  may  be  incised  either  directly,  if  it  can  be  detached  from  the 
pancreas,  or  through  the  tissue  of  this  viscus.  Dr.  T.  A.  McGraw,  of 
Detroit,  adopted  this  latter  plan  successfully,  having  first  made  certain  of 
the  stone  by  a  puncture  with  an  exploring  needle.  This  most  capable 
operator  is  inclined  to  think  that  an  incision  into  the  duct  through  the 
pancreas  is  preferable  to  one  through  the  duct  wall  only,  as  the  surgeon 
is  thereby  enabled  to  apply  two  or  three  tiers  of  sutures. f  (3)  The  stone 
may  be  removed  through  an  incision  in  the  duodenum,  adopted  by  Dr. 
McBurney,  of  New  York,  Ma3'o  Eobson,  and  others,  or  a  finger  intro- 
duced through  the  incision  in  the  bowel  may  dislodge  the  stone  and 
enable  it  to  be  pushed  upwards  into  a  more  accessible  point  in  the  com- 
mon duct  where  choledochotomy  mav  be  performed.  The  opening  in 
the  intestine  is  subsequently  sutured.  This  plan  is  spoken  highly 
of  by  Maj^o  Robson,  who  has  adopted  it  seven  times,  five  of  the 
patients  recovering.  He  says  "  for  calculi  situated  in  the  lower  third 
of  the  common  duct,  especially  if  impacted  in  the  diverticulum  of  Vater, 
the  operation  is  decidedly  preferable  to  the  ordinary  choledochotomy,  as 
not  only  is  it  easier,  but  an  incision  of  the  narrow  orifice  of  the  bile- 
duct  in  the  duodenum  leaves  a  patent  opening,  which  will  allow  any 
other  concretions  that  may  have  escaped  observation  to  pass  without 
difficulty." 


CHOLECYSTENTEROSTOMY. 

In  this  operation  a  communication  is  made  between  the  gall-bladder 
and  the  small  or  large  intestine.  Whenever  feasible  the  duodenum  or 
upper  jejunum  sliould  be  preferred.  AVhen  the  small  intestine  is  too 
matted  by  adhesions  to  come  up  sufficiently,  the  hepatic  flexure  of  the 
colon  should  be  chosen.  It  has  received  great  impetus  lately  owing  to 
the  recommendations  which  it  has  received  from  Dr.  Murphy,  of  Chicago, 
the  facility  with  which  it  can  be  performed  with  his  most  ingenious  and 
expeditious  button,  and  the  good  results  which  the  published  cases  show. 
The  chief  indications  for  the  operation  are  :  ( i )  Irremediable  obstruc- 
tion of  the  common  duct,  due  to  calculus  or  cicatricial  contraction.  The 
second  cause  is  very  rare,  and  it  is  probable  that  as  time  goes  on  and 
surger}^  proves  what  can  be  done  for  calculi  impacted  here,  this  indication 
will  very  rarely  arise.  (2)  In  obstruction  of  the  cystic  duct,  where 
cholecystectomy  is  impracticable.  (3)  A  per.^istent  fistulous  opening 
after  operations  on  the  gall-bladder,  or  due  to  stricture,  or  occlusion  of  the 


*  A  stone,  impacted  in  the  duct,  low  down,  may  give  a  hard  or  nodular  feel  which 
may  suggest  malignant  disease  of  the  head  of  the  pancreas  :  an  exploring  needle  will 
clear  up  the  case. 

f  It  is  noteworthy  that  in  Dr.  McGraw's  case,  the  jaundice  and  the  itching  were 
both  intensified  for  the  two  days  which  followed  the  operation.  This  was  attributed 
to  obstruction  from  a  Ijlood  clot  or  due  to  swelling  of  the  incised  tissues.  It  is  just 
possible  that  it  may  have  been  due  to  over-complete  suturing.  If  the  duct  is  not 
dilated  there  must  always  bo  a  risk  of  closing  its  lumen  for  a  time. 


CPIOLECYSTEXTEROSTOMY.  365 

common  duct,  giving  rise  to  a  constant  escape  of  bile,  causing  persistent 
excoriation  and  anno^'ance.  owing  to  the  eczematous  rawness.  In  such 
cases  the  operation  of  cholecystenterostomy  was  recommended  ten 
years  ago  in  this  country  by  Mr.  Willett  (Brit.  Med.  Journ.,  vol.  ii.  1886, 
p.  903).     (4)  Mayo  Robson  also  gives  chronic  pancreatitis. 

(5)  Another  indication  which  has  been  sometimes  given  is  malignant 
disease  about  tlie  head  of  the  pancreas  occluding  the  common  duct  and 
giving  rise  to  jaundice,  itching.  &c.  In  such  cases  cholecystenterostomy 
must  involve  greatly  increased  risk.  Haemorrhage  and  imperfect  repair 
are  the  chief  dangers,  the  first  especialh^  so,  as  will  be  seen  from  the 
case  given  below  of  Dr.  F.  J.  Shepherd  of  Montreal  (p.  367).  Dr. 
Murphy  himself  (Chicago  Clin.  Ber..  Feb.  1895)  considers  the  operation 
here  very  unsatisfactory,  there  having  been  seven  deaths  out  of  the 
eight  cases.  Two  died  from  shock,  one  from  a  twisting  of  the  small 
intestine,  before  the  approximation  was  made,  a  volvulus  being  thus 
produced.  In  another  case  the  gall-bladder  was  so  friable  that  it  tore 
like  wet  paper  when  the  sutures  were  inserted,  and  after  the  button  was 
in  position  and  the  abdomen  closed,  the  friable  wall  gave  way  and 
peritonitis  followed.  Dr.  Murphy  accordingly  advised  that  if  the 
operation  be  made  use  of  in  case  of  obsti'uction  due  to  malignant 
disease,  it  should  only  be  in  the  early  stage. 

The  indications  for  cholecvstenterostomv  having  been  o-iven.  the 
means  of  performing  the  operation  will  next  be  considered.  These  are  : 
(i)  Suture  alone  ;  (2)  Suture,  aided  by  one  of  the  bobbins  now  coming 
into  use,  so  as  to  give  support  to  the  sutures  and  facilitate  their 
insertion.  Of  these.  ^Ir.  Robson's  is,  I  believe,  the  only  one  which 
has  been  used  as  yet.  Two  cases  are  very  briefl}^  given  (Brit.  Med. 
Journ.,  vol.  i.  1894.  p.  902).  In  one  of  them,  when  the  dilated  cystic 
duct  had  been  united  to  the  colon,  the  jaundice  recurred  a  few  months 
later.  (3)  Murphy's  button.  Cholecystenterostomy  by  this  method 
requires  careful  attention.  The  attractiveness  which  the  simplicity  of 
this  most  ingenious  device  must  always  carry  with  it,  the  success  *  which 
it  has  met  with  in  skilful  hands,  make  it  very  probable  that,  in  the  zeal 
of  securing  an  immediate  success,  this  operation  may  be  performed,  if  it 
had  not  already  been  so,  much  too  often.  Thus,  to  take  both  sides  of  the 
question,  on  the  one  hand  we  have  these  advantages  :  the  two  viscera 
which  are  to  be  united  are  often  readily  reached  by  a  comparatively 
small  incision.  The  button  is  very  quickly  adjusted,  the  bile  soon 
passes  b}^  the  new  channel,  the  jaundice  and  itching  are  lost  and  the 
faeces  again  become  natural.  On  the  other  hand  the  following 
ohjedions  present  themselves  to  every  candid  and  well-informed  thinker, 
(i)  It  is  clear  from  the  account  of  several  of  the  cases  that  the  cause  of 
all  the  trouble  might  have  been  removed,  and  not  only  relieved,  Tims, 
in  several,  stones  were  not  removed  from  the  gall-bladder,  and  the  ducts 
were  not  even  examined.!     Yet  these  cases  are  published  as  successes. 

*  Dr.  Murphy,  in  a  report  up  to  1897,  gives  sixty-seven  cases  of  cholecysten- 
terostomy for  non-malignant  obstructive  jaundice,  with  only  three  deaths, 

t  Dr.  McGraw,  of  Detroit,  and  Dr,  Elliot,  of  Boston,  both  bring  a  further  objection 
against  the  button  consequent  on  this,  that  it  often  leaves  behind  it  in  the  form  of  a 
stone  or  stones,  sources  of  irritation,  which  may  develop  later  into  conditions  of 
danger.  Time  must  show,  with  careful  watching  and  accurate  reporting  of  cases,  how 
far  this  criticism  is  justified. 


366 


OPERATIONS  ON  THE  ABDOMEN. 


As  this  operation,  rendered  so  simple  by  Murphy's  button,  is  likely  to 
be  resorted  to  in  cases  of  stone  impacted  in  the  three  bile  ducts,  it  is 
right  to  point  out  that  modern  methods  and  recent  experience  have 
rendered  removal  of  stones  by  incision  so  safe  in  skilled  hands  that  this 
step,  choledochotomy,  is  always  to  be  preferred,  when  possible,  to 
cholecystenterostomy.  In  other  words,  those  of  Dr.  McGraw  (Ann.  of 
Sure/.,  Aug.  1895,  p.  169)  "we  should  try  not  only  to  relieve,  but  also 
to  cure."  (2)  Another  objection,  though,  I  believe  only  proved  by  one 
case  as  yet,  is  that  of  septic  infection  of  the  ducts  and  liver  from 
the  intestine.  We  must  remember  how  very  different  are  the  conditions 
after  cholecystenterostomy,  to  those  in  health,  as  regards  a  communica- 
tion between  the  intestine  and  the  biliar}-  passages.     That  a  patient 

Fig.  157. 


Cholecysteuterostoniy  with  Murphy's  button.     (Down's  Pamphlet.) 


after  this  operation,  as  long  as  the  opening  remains  free,  must  be 
menaced  with  the  danger  of  septic  infection  is  proved  by  a  case 
reported  by  Eickard  (Bull.  80c.  Chir.,  t.  xx.  1894,  p.  572).  Here  death 
occurred  fift3'-three  days  after  cholecystenterostomy,  although  the 
patient  did  well  at  first.  The  necropsy  showed  that  death  was  due 
to  infection  of  the  biliary  passages  from  the  intestine,  numerous 
abscesses  due  to  ascending  infection  being  present.  (3)  There  is  the 
risk  of  contraction.  Unless  the  opening  is  made  ver}^  free,  this  may  set 
in  after  any  method.  (4)  Haemorrhage.  This  risk  must  be  present, 
however  cholecj'stenterostomy  is  performed,  in  cases  of  obstruction  from 
malignant  disease,  owing  to  the  tendency  to  hgemorrhage  in  these 
cases  ;  it  is  especially  likely  to  follow  the  use  of  Murphy's  button, 
whenever  a  thickened  condition  or  friability  of  the  tissues  prevents  the 
button  taking  that  grip  which  is  so  essential  for  success.     All  surgeons 


CHOLECYSTENTEROSTOMY.  367 

owe  much  to  Dr.  F.  C.  Shepherd,  of  Montreal,  for  the  candid  way 
in  which  he  has  drawn  their  attention  to  this  fact  (Ann.  of  Sttnj.,  May 
1893,  p.  581): 

His  patient,  aged  36,  bad  a  biliary  fistula  resulting  from  a  previous  cbolecyst- 
ostomy  for  jaundice,  pain,  kc,  performed  four  months  previously,  when  no 
stone  was  found.  Owing  to  the  annoyance  of  the  continual  discharge  of  bile,  the 
abdomen  was  opened  again  by  an  incision  internal  to  the  old  fistula,  and  a  mass  of 
malignant  disease  was  now  found  involving  the  pancreas  and  duodenum.  It  was 
decided  to  unite  the  gall-bladder  with  the  colon  instead  of  the  duodenum,  '•  as  being 
easier  and  more  rapid,  and  quite  as  beneficial."  The  button  was  introduced  without 
very  much  difliculty,  the  purse-string  suture  being  first  inserted.  Owing  to  the 
thickness,*  of  the  gall-bladder  there  was  some  puckering,  and  the  parts  did  not  come 
together  without  considerable  pressure  on  the  button.  On  dropping  back  the  bowel 
and  gall-bladder  with  the  button  there  was  no  tension,  and  the  parts  seemed  to  be  in 
accurate  apposition,  and  to  lie  comfortably.  It  was  decided  not  to  close  the  fistulous 
opening,  as  it  was  felt  that  this  would  close  of  itself.  On  the  morning  of  the  fourth 
day  (the  patient  having  gone  on  well  in  the  interval)  blood  was  found  to  be  oozing 
from  the  gall-bladder  and  the  abdominal  wound.  In  spite  of  gauze-packing  this 
continued,  and  the  patient  passed  into  a  state  of  collapse.  On  opening  the  abdominal 
wound  it  was  seen  that  the  haemorrhage  came  entirely  from  the  gall-bladder.  The 
button  had  cut  through  the  thick  and  friable  walls,  and  could  be  easily  seen.  To 
remove  the  button  it  was  necessary  to  incise  both  gall-bladder  and  bowel  and  unscrew 
the  button.  It  being  useless  to  reinsert  the  button,  it  was  decided  to  sew  up  the 
openings  in  the  gall-bladder  and  colon.  A  fresh  oozing  took  place  about  twenty-four 
hours  later,  and  the  patient  sank.  A  partial  necropsy  showed  that  the  obstruction  of 
the  common  duct  was  due  to  malignant  disease  of  the  head  of  the  pancreas. 

Kiister  (^Verliandl.  d.  Deut.  Gcsellscli.f.  Chir.,  April  1861),  reports  a  case  in  which 
two  stones  had  been  removed  by  incision  of  the  dilated  common  duct,  the  opening 
being  closed  by  a  double  row  of  sutures.  Gauze-drainage  was  employed.  Eleven  days 
after  the  operation,  hemorrhage  took  place  from  the  drain-tract,  this  was  arrested  by 
the  thermo-cautery,  and  fresh  packing  with  iodoform  gauze.  The  patient  recovered, 
and  a  year  later  passed  two  stones. 

(5)  The  button  may  not  be  passed.  This  happened  in  a  case  of  Dr. 
Briddon's  (New  York  Surg.  Soc,  1896).  Here  the  bladder  was  dilated 
with  non-contractile  walls.  The  button  probably  fell  into  this  viscus  as 
the  larger  chamber,  and  there  remained,  two  months  later,  without 
causing  inconvenience.  Two  other  objections  are  brought  against 
cholecystenterostomy  by  Dr.  McGraw.  (6)  It  produces  adhesions 
between  previously  detached  organs,  adhesions  which  may  interfere 
with  their  movements  and  with  their  actions.  (7)  After  this  operation 
the  bile  is  diverted  through  the  cystic  duct  and  gall-bladder  into  the 
bowel.  The  gall-bladder  takes  on  itself  the  function  of  the  common 
duct,  and  the  common  duct,  remaining  patulous  at  its  upper  end, 
receives  a  certain  amount  of  bile  which  stagnates  under  conditions 
which  favour  its  crystallisation,  especially  if.  as  is  often  the  case, 
the  common  duct  already  contains  stones. f 

*  It  will  be  noticed  that  no  mention  is  made  of  the  gall-bladder  being  friable,  the  con- 
dition which  was  found,  a  little  later,  to  have  contributed  so  largely  to  the  fatal  result. 

f  "  Here  then  we  have  the  beginning  of  a  morbid  condition  of  which  no  man  can 
foresee  the  end.  There  is  no  reason  why,  in  the  course  of  time,  the  obstructed  duct  may 
not  become  full  to  overflow  with  numberless  gall-stones  which  could  not  fall  in  this 
receptacle  to  cause  fully  as  much  disturbance  as  in  the  gall-bladder  itself."  Only 
careful  watching  of  cases  can  prove  whether  the  above  criticisms  are  true.  Those 
surgeons  who  are  familiar  with  Dr.  McGraw's  work  will  feel  with  me  that  they  cannot 
be  lightly  passed  over. 


368  OPEIIATIOXS  OX  THE  ABDOMEN. 

Of  the  three  methods  above  mentioned,  however,  that  by  means  of 
Murphy's  button,  in  spite  of  the  above  objections,  is  certainly  the 
best  to  adopt  on  account  of  its  rapidity  and  efficiency  as  shown  by 
the  results  given  above.  Moreover,  Mr.  M.  Robson  has  now  himself 
discarded  his  bobbin  for  the  Murphy  button,  which  he  has  used  fifteen 
times  with  three  deaths.  The  operation  itself  is  similar  to  others  in 
which  the  button  is  employed,  and  does  not  require  any  special 
description. 


CHOLECYSTECTOMY. 

The  indications  for  this  operation  as  given  by  Mayo  Robson  (loc. 
sup'a  cit.)  are  as  follows  :  "  (i)  In  bullet  wound  or  other  wound  of  the 
gall-bladder  where  suture  is  impracticable.  (2)  In  phlegmonous 
cholecystitis.  (3)  In  gangrene  of  the  gall-bladder.  (4)  In  multiple,  or 
in  perforating  ulcers.  (5)  In  chronic  cholecystitis  from  gall-stones, 
where  the  gall-bladder  is  shrunken  and  too  small  to  safely  drain,  and 
where  the  common  duct  is  free  from  obstruction.  (6)  In  mucous 
fistula  due  to  stricture  of  the  cystic  duct.  (7)  In  hydrops  of  the  gall- 
bladder due  to  stricture  of  the  cystic  duct ;  as  also  in  certain  cases 
where  the  gall-bladder  is  very  much  dilated.  (8)  In  certain  cases 
of  empyema,  where  the  walls  of  the  gall-bladder  are  very  seriously 
damaged.     (9)  In  cancer  of  the  gall-bladder." 

Operation. — Sufficient  room  having  been  provided  by  a  free  longi- 
tudinal incision  prolonged  lateral!}"  along  the  costal  margin  towards 
the  middle  line,  or  by  a  free  transverse  or  semilunar  incision  (p.  354), 
the  contents  of  the  peritonseal  sac  are  shut  off  with  flat  sponges  or 
tampons  of  sterile  gauze  before  the  adhesions  of  the  gall-bladder 
are  separated.  These  will  xoxy  greatly.  In  a  normal  case  they  will  be 
simple,  and  all  that  is  needful  is  to  divide  the  reflexion  of  peritonaeum 
which  passes  from  the  liver  over  the  gall-bladder,  and  then  to  shell  out 
the  latter  from  its  fossa  by  gently  tearing  through  the  connective  tissue 
and  vessels  w^hich  hold  it  in  place,  with  the  finger  or  a  pair  of  curved 
scissors,  these  being  used  as  a  blunt  dissector  as  well  as  to  cut  with. 
In  cases,  on  the  other  hand,  where  there  is  much  matting  of  the  parts, 
the  omentum,  duodenum,  colon,  pylorus  may  all  require  most  careful 
detachment,  bit  by  bit,  before  the  gall-bladder  is  reached,  lying  far 
from  the  surface,  puckered  and  shrunken.  And  when  this  is  effected, 
repeated  attacks  of  inflammation  may  have  converted  its  immediate 
surroundings  into  a  compartment  of  sclerosed  fibro-fatty  tissue  out  of 
which  it  has  to  be  shelled  like  a  kidney,  the  site  of  long-standing 
calculous  pyelitis,  from  out  of  its  thickened,  matted  cupsule.  Friability 
of  the  walls  of  the  gall-bladder,  these  tearing  away  on  the  slightest 
traction,  is  another  difficulty  which  may  be  very  present  with  a  deep- 
lying  viscus.  The  gall-bladder  having  been  separated  as  far  back  as 
the  cystic  duct,  the  first  part  of  this  is  isolated,  and  its  distal  extremity 
tied  with  sufficientlj^  stout  sterilised  silk.  Two  ligatures  should  be  tied 
and  an  aneurysm-needle  may  be  useful  here.  Care  must  be  taken  not 
to  include  the  hepatic,  and  still  more  the  common  duct,  in  cases  where 
the  depth  of  the  wound  and  adhesions  may  make  the  relations  of  parts 
uncertain.     Before  severing  the  duct  it  will  be  well,  if  two  ligatures 


CnOLECY^^TECTOMY.  369 

have  not  been  passed,  to  close  its  proximal  end  with  clamp  forceps  so 
that  no  bile  escapes  when  it  is  divided.  Any  mucous  membrane  which 
projects  from  the  cut  end  should  be  treated  with  a  little  pure  carbolic 
acid,  or  it  may  be  treated  like  the  stump  of  an  appendix  by  drawing 
the  cut  edges  of  the  serous  coat  together  by  one  or  two  stitches  of  fine 
catgut. 

The  bleeding,  chiefly  of  the  nature  of  oozing,  usually  yields  to  well- 
applied  pressure  ;  any  bleeding  points  which  cannot  be  tied  oflF  must  be 
treated,  as  in  all  operations  on  the  bile-passages  which  present  a  like 
diflaculty,  by  leaving  on  Spencer  Wells's  forceps  for  twenty-four  or 
thirty  hours,  a  step  which  will  also  facilitate  drainage.*  The  parietal 
wound  A\'ill  usually  be  only  closed  above,  as  in  most  cases,  owing  to 
some  uncertainty  as  to  the  perviousness  of  the  ducts  below,  or  bleeding 
from  adhesions,  it  will  be  well  to  employ  drainage  together  with  gauze 
packing. 

Treatment  of  Biliary  Fistula. — This  most  troublesome  affection 
usually  follows  on  cholecystostomies.  It  has  already  been  alluded  to, 
but  owing  to  its  importance  and  the  difficulties  which  surround  it,  a  few 
more  words  are  required.  If  of  any  duration  it  depends,  usually,  upon 
one  or  two  causes — a  stone  impacted  in  the  common  duct,  or  malignant 
disease  of  the  head  of  the  pancreas.  The  annoyance  from  the  constant 
discharge,  the  difficulty  of  collecting  this,  the  frequent  change  of 
dressings  necessitated  Avhen  the  patient  is  about,  the  eczema  and 
raM-ness  around  the  ^\■ound,  are  very  great.  In  the  case  of  an  impacted 
<tone,  if  it  cannot  be  felt  and  removed  or  dislodged  by  manipulations 
from  the  adherent  gall-bladder,  the  abdomen  should  be  freely  opened 
by  an  incision  to  the  inner  side  of  the  fistula,  exposing  the  gall-bladder 
adherent  to  the  parietes ;  the  ducts  are  then  examined  and  the  stone 
localised  in  the  common  duct,  and  either  broken  up,  or  pushed  on  or 
removed  by  incision.  If  the  above  course  is  really  impracticable, 
cholecystenterostomy  must  be  performed.  In  the  very  rare  cases  where 
the  obstruction  is  due  to  contraction  which  has  set  in  after  ulceration 
due  to  the  long-continued  pressure  of  a  stone,  the  surgeon  should  try  to 
open  up  the  duct  with  probes  and  sounds  passed  from  an  opening  in 
the  gall-bladder,  aided  by  a  finger  within  the  peritongeal  sac.  Where 
it  is  found  that  malignant  disease  is  the  cause  of  the  obstruction,  if  this 
be  in  an  early  stage  (p.  365),  the  patient's  power  of  repair  good,  and 
the  blood  not  yet  seriously  altered,  cholecystenterostomy  should  be 
performed. 


*  If  oozing  from  the  liver  substance  is  not  checked  by  efficient  and  prolonged  sponge 
I)ressure;  tamponnading  with  iodoform  gauze  or  the  thermo-cauterj  must  be  employed. 


VOL.   II.  24 


CHAPTER   X. 
OPERATIONS    ON    THE    PANCREAS. 

TREATMENT    OF    PANCREATIC    CYSTS.— ACUTE 
PANCREATITIS. 

TREATMENT     OP    PANCREATIC     CYSTS. 

Diagnosis  of  Pancreatic  Cysts. — Sufficient  cases  have  been  published 
to  make  the  following  probably  reliable  : — The  swelling,  which  may 
date  to  an  accident,  appears,  usually  in  an  adult,  in  the  epigastric 
region,  is  generally  accompanied  (especially  when  its  increase  is  rapid) 
by  "  coeliac  neuralgia  " — i.e.,  pains  probably  arising  in  the  solar  plexus 
— often  colicky,  or  even  agonising,  and  leading  to  collapse.  Dvspepsia, 
marasmus,  and  mental  depression  are  often  present  to  a  marked  degree. 
The  position  of  the  cyst,  behind  the  stomach  and  transverse  colon,  and 
the  chemical  and  microscopical  examination  of  the  fluid  are  well  worthy 
of  attention. 

Treatment. — Dr.  Senn  showed  that  the  wisest  course  was  incision  of 
the  c_vst  by  abdominal  section.  The  results  of  attempting  to  extirpate 
the  cyst  have  been  so  unsuccessful  as  to  entirely  justify  his  condemna- 
tion of  this  course. 

The  following  case,*  in  which  I  operated  at  the  request  of  Dr.  Newton 
Pitt,  is  a  good  instance  of  a  pancreatic  cyst  treated  by  laparotomy, 
incision,  and  drainage  : — 

I  received  the  following  history  when  asked  to  see  the  case,  August  21,  18S9:  The 
patient  was  21.  He  had  received  a  kick  in  the  abdomen  three  years  before,  which  had 
confined  him  to  bed  for  three  weeks.  Ever  since  he  had  been  liable  to  severe  attacks 
of  epigastric  pain.  He  had  been  markedly  jaundiced,  was  emaciated,  and  suffered  a 
good  deal  from  nausea  and  depression.  The  swelling  in  the  epigastric  region  was 
convex  and  uniform,  and  reached  from  below  the  tip  of  the  ensiform  cartilage  to  just 
above  the  umbilicus,  and  laterally  to  near  the  ends  of  the  eleventh  ribs.  The  tumour 
gave  the  impression  of  being  attached  to  some  deep-seated  structure.  There  was 
transmitted  impulse  synchronous  with  the  pulse,  but  not  expansile.  As  the  swelling 
had  refilled  after  two  previous  tappings,!  and,  as  the  swelling  and  the  patient's  distress 


*  My  colleague  and  I  reported  this  case  fully  (Trans.  Med.-Chir.  Soc,  vol.  Ixxiv. 
p.  455).  Eeferences  are  given  to  thirty  cases  which  will  be  found  summarised  there  by 
Dr.  Pitt.  References  are  also  made  to  thirteen  cases  by  Mr.  Cathcart  in  his  instructive 
paper  (^Edin.  Med.  Journ.,  July  1890). 

+  The  fluid  was  alkaline,  sage-green,  sp.  gr.  1013,  albuminous,  and,  under  the  micro- 
scope, showing  innumerable  collections  of  globular  masses  of  tyrosin  crystals.     No- 


TREATMENT   OF  PANX'EEATIC  CYSTS.  37 1 

were  steadily  increasing,  laparotomy  \vas  performed,  August  22,  with  strict  antiseptic 
precautions.  An  incision,  three  inches  long,  was  made  over  the  most  prominent  part 
of  the  cyst,  an  inch  and  a  half  to  the  left  of  the  middle  line,  extending  to  within  an  inch 
of  the  umbilicus.  The  parietal  peritonaeum  having  been  stitched  to  the  margins  of  the 
wound,  the  lower  edge  of  the  liver  could  be  seen  moving  with  respiration  in  the  upper 
angle,  while  the  rest  of  the  incision  was  occupied  by  a  smooth  reddish  surface,  which 
bulged  strongly  forwards.  Taking  this  to  be  the  front  of  the  cyst,  and  having  ascer- 
tained before  the  operation  that  the  cyst  was  dull  on  percussion.  I  was  about  to  leave 
this,  for  twenty-four  hours,  to  become  adherent  before  it  was  incised.  The  result 
proved  that,  if  I  had  done  so,  the  scalpel  would  have  passed  through  both  walls  of  the 
stomach.  Before  dressing  the  wound.  I  again  scrutinised  the  surface  of  the  supposed 
cyst,  and  thought  I  found  evidence  of  involuntary  muscular  fibre,  which  threw  doubts 
upon  the  swelling  being  a  pancreatic  cyst.  When  the  supposed  cyst  was  examined 
between  the  fingers,  it  proved  to  be  the  empty  stomach,  stretched  very  tightly  over  the 
subjacent  cyst.  To  get  at  this,  the  stomach  was  drawn  upwards,  that  it  might  be 
packed  away  above  under  the  liver.  But  here  an  embarrassing  difficulty  arose.  As  I 
pulled  up  the  stomach,  which  was  tightly  jammed  between  the  bulging  cyst  behind 
and  the  parietes  in  front,  the  omentum  came  up  into  the  wound  in  front  of  the  cyst. 
The  tension  of  the  parts  was  so  great,  owing  to  the  rapid  increase  in  the  cyst,  thai 
there  was  no  room  above  in  which  to  pack  away  the  omentum.  Pushing  this  to  either  side 
already  fully  occupied,  pulled  down  the  stomach  again.  I  accordingly  drew  the  oreater 
part  of  the  omentum  out  of  the  wound.*  Some  of  it  was  tied  with  catgut,  and  cut 
away ;  much  of  it  was  left  heaped  up  on  the  abdominal  walls  on  either  side  of  the 
incision.  One  or  two  fine  catgut  sutures  retained  the  omentum  in  position.  I  next 
scratched  throiigh  the  two  layers  of  omentum,  and  exposed  the  surface  of  the  cyst  for 
a  space  the  size  of  a  shilling.  There  was  thus  a  somewhat  conical  passage  leadino- 
from  the  abdominal  incision,  through  a  mass  of  omentum,  down  to  the  anterior  surface 
of  the  cyst.  This  last  was  very  vascular,  and  so  tense  that  it  was  not  thought  advisable 
to  put  in  a  guide-suture.  The  patient  passed  through  the  next  twenty-four  hours 
fairly  well.  At  midnight,  August  23,  symptoms  of  collapse  set  in  (hfemorrhage 
probably  took  place  at  this  time  into  the  cyst,  a  complication  which  must  alwavs- 
be  probable,  owing  to  the  very  vascular  sitrroundings).  The  patient's  piilse  at  2  a.m. 
had  run  up  to  163,  and  his  condition  pointed  to  a  fatal  ending  at  no  distant  date.  At 
3  A.M.  I  passed  a  fine  trocar  into  the  cyst,  and  drew  off  12  oz.  of  deeply  blood-stained 
fluid,  which  was  under  very  high  tension.  The  sac  was  then  incised  and  a  large 
drainage-tube  inserted.  A  marked  improvement  at  once  set  in.  A  slight  discharge  of 
dark  treacly  fluid  necessitated  changing  the  dressing  twice  a  day  at  first.  The  wound 
was  all  healed  in  two  months  (vide  infra). 

On  another  occasion  I  should  prefer  to  open  the  cyst  at  once  either 
by  a  large  trocar  and  tubing,  or  by  a  small  incision,  keeping  the  cvst 
well  forwards  by  means  of  Spencer  Wells"s  forceps  attached  to  the  cut 
edges.  Theii,  as  the  cyst  emptied,  a  finger  as  a  guide  having  been 
introduced  into  the  cyst  and  pushed  downwards  and  outwards  below 
the  left  infra-costal  margin,  a  counter-opening  might  be  made  and  a 
large  drainage-tube  inserted  into  the  cyst  from  behind.     This  would  be 

leucin  could  be  detected.  The  fluid  in  these  cysts  varies  a  good  deal — sometimes 
colourless  and  serous,  at  others  it  is  red  and  viscid.  It  will  be  seen  from  the  account 
that  follows  that  on  each  occasion  the  aspirating  needle  must  have  transfixed  the 
stomach.  The  same  thing,  with  like  harmlessness.  happened  in  one  of  Karewsky's  two 
cases  (Deut.  Med.  Woch.,  No.  46,  1890).  In  two  cases  the  preliminary  puncture  was 
followed  by  evidence  of  peritonitis,  and  in  two  by  grave  collapse  attending  the  escape 
of  fluid  from  the  cyst  into  the  peritonfeal  sac.  Another  possible  danger  is  puncture  of 
the  transverse  colon,  which  may  be  tightly  stretched  over  the  cyst.  If  fluctuation  can 
be  detected  in  the  infra-costal  region  behind,  or  if  a  thrill  can  be  obtained  here  from 
the  front,  it  will  be  safer  to  aspirate  from  behind. 
*  On  another  occasion  I  should  divide  the  omentum  above  the  trajisverse  colon. 


372  OPERATIONS  ON  THE  ABDOMEN. 

sliortened  from  time  to  time,  as  gradual  contraction  of  the  cyst  took 
place.  The  anterior  opening  in  the  cyst  could  be  either  sutured,  or 
attached  to  the  margins  of  the  abdominal  incision.  Mr.  Cathcart  left 
the  opening  in  the  front  of  the  cj^st  open,  Mr.  A.  P.  Gould  closed  his 
by  suture. 

Mr.  Caird  (Ed.  Med.  Journ.,  Feb.  1896)  acting  on  Mr.  Cathcart's  plan 
of  making  a  counter-oj)ening  behind,  opened  one  of  these  cysts  at  the 
back,  and  not  through  the  anterior  abdominal  wall,  as  is  usually  done. 
The  incision  was  made  along  the  outer  border  of  the  erector  spinge  just 
below  the  twelfth  rib,  and  a  tube  inserted.  This  was  kept  in  for  four 
months,  and  later  on  iodine  was  injected  occasionally  to  promote  obli- 
teration of  the  cyst.  The  patient  was  ultimately  discharged,  with  the 
opening  closed.  The  administration  of  liquor  pancreaticus  with  the 
food  was  thought  to  have  been  beneficial.  All  will  agree  with  what 
Mr.  Cathcart  claims  for  the  posterior  incision,  viz.,  (i)  that  the  cyst  can 
here  be  reached  extra-peritonseally ;  (2)  that  this  incision  gives  better 
drainage  ;  and  (3)  that  by  it  there  is  less  risk  of  a  ventral  hernia. 

The  after-history  of  any  case  of  pancreatic  cyst  reported  as  cured  by 
drainage  must  be  carefully  watched.  It  is  clear  that  under  certain 
conditions — e.g.,  where  the  cyst  is  very  large,  where  it  has  thick  walls, 
and  above  all  where  the  duct  communicates  with  the  cyst  and  where 
much  of  the  tissue  of  the  pancreas  remains — recurrence  is  almost  certain 
and  complete  oblitei'ation  by  drainage  probably  impossible.  As  in  most 
of  these  cases  the  intimate  relation  of  these  cysts  with  very  vital  parts 
does  not  admit  of  their  being  dissected  out,  we  must  be  prepared  to  fail 
sometimes  in  our  efforts  to  secure  a  radical  cure.  This  is  shown  by  the 
sequel  to  Dr.  Newton  Pitt's  and  ni}^  case,  which  was  brought  as  one 
treated  successfully  b}"  drainage,  before  the  Medico-Chirurgical  Society 
(vide  supra).  About  a  year  later  I  heard  that  the  swelling  had  reap- 
peared and  that  the  man  was  about  to  be  operated  on  again.  Later  on 
I  v/as  given  to  understand  that  the  swelling  had  reappeared  a  second 
time,  but  I  have  been  unable  to  obtain  the  needful  information.  Dr.  M. 
H.  Richardson,  of  Boston,  drew  attention  to  this  tendency  of  pancreatic 
cysts  to  recur  after  drainage.  "  Pancreatic  Cysts  apparently  cured  b}' 
Incision  and  Drainage ;  Recurrence ;  Perforation  of  the  Stomach ; 
Death;  Autopsy"  (Boston  Med.  and  Surg.  Journ.,  vol.  cxxvi.  1892, 
p.  441).  At  the  necropsy  it  was  found  that  the  head  of  the  pancreas  was 
normal,  and  that  a  tube  could  be  passed  from  the  pancreatic  duct  into 
the  cyst ;  about  two  inches  of  normal  pancreatic  tissue  were  found  lying 
between  the  cyst  and  the  spleen.  From  this  also  a  duct  could  be  traced 
into  the  cyst.  It  was  very  difficult  and  even  impossible  at  the  time  of 
the  necropsy  to  dissect  out  the  cyst  from  the  parts  to  which  it  was 
adherent.  Dr.  Richardson  thinks  that  in  some  cases  the  permanent  use 
of  a  tube  will  be  needful.  Mr.  A.  P.  Gould  published  (Lancet,  vol.  ii. 
1 89 1,  p.  290)  a  case  of  pancreatic  cyst  which  had  been  treated  by 
drainage,  a  sinus  persisted  in  spite  of  treatment,  and,  three  years  later, 
became  the  site  of  epitheliomatous  infiltration.  Dr.  0.  Ramsey,  of 
Baltimore,  in  a  case  of  a  large  pancreatic  cyst  treated  by  drainage,  was 
obliged  to  continue  the  use  of  a  drainage-tube  seven  months  after  the 
operation,  as  the  discharge  was  still  free  (An7i.  of  Surg.,  Dec.  1895). 
Dr.  Ramsey  thinks  that  in  addition  to  persistence  of  secretion  the  large 
size  of  the  cyst  and  the  tension  under  which  the  fluid  escapes  when  the 


ACUTE  PAXCREATITIS.  373 

cyst  is  opened,  point  to  gland  substance  being  present  and  still  func- 
tionally active.  The  last  two  features,  it  will  be  noticed,  were  present 
in  Dr.  N,  Pitt's  and  my  case,  which  recurred  after  an  apparent  cure. 


ACUTE    PANCREATITIS. 

The  first  accurate  account  of  this  rare  disease  was  given  by  Fitz  {New 
YorJi  Med.  Becord,  1889).  Since  then  a  number  of  cases,  about  forty  in 
all,  have  been  recorded  by  various  observers. 

The  chief  symptoms,  as  summarised  by  Fitz,  are  : — "  Sudden,  severe, 
often  intense  epigastric  pain,  without  obvious  cause,  in  most  cases 
followed  by  nausea,  vomiting,  sensitiveness,  and  tympanitic  swelling  of 
the  epigastrium.  There  is  prostration,  often  extreme,  frequent  collapse, 
low  fever,  and  a  feeble  pulse.  Obstinate  constipation  for  several  days 
is  the  rule,  but  diari'hoea  sometimes  occurs.  If  the  case  does  not  end 
fatally  in  the  course  of  a  few  days,  recover}^  is  possible,  or  a  recurrence 
of  the  sjnnptoms  in  a  milder  form  takes  place,  and  the  characteristics  of 
a  subacute  peritonitis  are  developed." 

Very  few  of  the  cases  have  been  correctly  diagnosed,  the  majority,  as 
will  be  readily  understood  by  consideration  of  the  above-mentioned 
symptoms,  having  been  thought  to  be  either  acute  peritonitis  or  acute 
intestinal  obstruction,  usually  the  latter. 

In  a  few  instances  the  presence  of  an  epigastric  tumour  has  materially 
aided  the  diagnosis ;  such  cases  have  been  recorded  by  Thayer  {Amer. 
Journ.  of  Med.  Sci.,  vol.  ex.),  Pitt  (Clin.  Soc.  Trans.,  vol.  xxxii.),  and 
others.  In  Thayer's  case,  abdominal  section  revealed  the  presence  of  an 
abscess  in  connection  with  the  pancreas,  drainage  of  which  resulted  in 
recovery.  In  Dr.  Pitt's  case,  the  tumour  was  chiefly  due  to  blood 
effusion  in  and  around  the  pancreas. 

Treatment. — The  uncertainty  of  the  diagnosis,  or  the  fact  that  acute 
pancreatitis  was  unsuspected,  has  led,  in  the  majority  of  cases,  to  the 
performance  of  an  exploratory  laparotomy.  Should  such  an  operation 
be  performed  on  a  patient  supposed  to  be  suffering  from  either  acute 
intestinal  obstruction  or  acute  peritonitis  with  a  negative  result,  the 
possibility  of  acute  pancreatitis  must  be  considered.  The  following 
points  will  be  found  useful  under  such  circumstances : 

(i)  Fat-necrosis  may  be  present.  This  occurs  in  the  form  of  small 
patches,  circular  or  oval  in  shape,  and  of  an  opaque  white  or  yellow 
appeai'ance,  scattered  about  the  fat  over  the  pancreas,  the  omentum  and 
the  mesenterj^.  If,  on  careful  inspection  with  a  good  light,  evidence  of 
fat-necrosis  is  found,  it  may  be  inferred  that  some  serious  lesion  of  the 
pancreas  is  present.  Absence  of  fat-necrosis,  on  the  other  hand,  does 
not  exclude  the  possibility  of  acute  pancreatitis. 

(2)  Stcelling  of  the  Pancreas  on  Palpaiion. — This  may  be  due  to 
inflammatory  exudation,  blood  eftusions,  or  a  collection  of  pus.  In 
order  to  further  examine  the  pancreas,  it  must  be  approached  either 
through  the  small  or  great  omentum,  whichever  is  found  to  be  the 
more  convenient. 

If  a  diagnosis  of  acute  pancreatitis  is  made  either  before  or  after 
exploratory  laparotomy,  the  further  treatment  will  depend  upon  the 
particular  condition  of  the  pancreas  that  is  found  to  be  present. 


374  OPERATIONS  OX  THE  ABDOMEN. 

Should  an  abscess  be  present,  this  must  be  opened  and  drained. 
Mr.  Mayo  Robson  (Brit.  Med.  Journ.,  May  ii,  1901)  recommends  a 
vertical  posterior  incision  in  the  left  costo- vertebral  angle  for  this 
purpose.  Such  an  incision  would  certainly  be  more  favoiirably  placed 
for  the  purposes  of  drainage  ;  great  care,  however,  would  have  to  be 
exercised  in  carrying  out  this  plan  in  view  of  the  important  structures 
which  might  be  injured. 

If  it  is  decided  not  to  make  an  opening  behind,  the  abscess  must  be 
packed  with  iodoform  gauze  and  drained  through  the  anterior  incision. 

If  hgemorrhage  in  and  around  the  pancreas  is  found,  clots  may  be 
rapidly  removed  and  the  cavity  packed  with  tampons  of  iodoform 
gauze. 

Owing  to  the  extremely  serious  condition  that  the  patient  is  usuallj^ 
in,  every  possible  precaution  must  be  taken  to  avoid  shock,  and  the 
operation  itself  must  be  performed  as  rapidly  as  possible. 


CHAPTER  XI. 
OPERATIONS  ON  THE  BLADDER. 

BEMOVAL  OF  GROWTHS  OF  THE  BLADDER. — OPERATIVE 
TREATMENT  OF  TUBERCULAR  ULCERATION.  —PARTIAL 
PROSTATECTOMY.  —  LATERAL  LITHOTOMY.  —  SUPRA- 
PUBIC  LITHOTOMY. — MEDIAN"  LITHOTOMY. —  LITHO- 
TRITY  AND  LITHOLAPAXY.— PERINEAL  LITHOTRITY. 
—REMOVAL  OF  STONE  IN  THE  FEMALE. — CYSTOTOMY. 
RUPTURED  BLADDER. 

REMOVAL  OF  GROWTHS  OF  THE  BLADDER. 

Practical  Points  in  the  Diagnosis.- — Early  and  accurate  diagnosis  is 
here  of  the  utmost  importance. 

I.  Hcemorrhage. — This  is  of  much  importance,  both  in  diagnosis  and 
as  bearing  upon  an  operation.  Thus,  in  the  villous  growth  or  fimbriated 
papilloma  it  is  this  alone  which  kills.  Again,  it  may  be  the  only 
sj'mptom.  In  these  growths  the  chief  point  is  that  the  hgemorrhage 
extends  over  a  long  time,*  occurs  spontaneously  and  suddenly",  and 
without  any  allied  symptoms  ;  it  ceases  in  the  same  way ;  the 
periods  of  intermission  gradually  become  less,  till  the  bleeding  is  con- 
stant, either  rendering  the  patients  utterly  anaemic  or  adding  to  their 
misery  by  bringing  about  cystitis.  These  two  last  conditions  may  be  so 
marked  as  to  demand  an  operation.  This  symptom  is  most  frequent  in 
the  villous  gro^\i:h  (fimbriated  papilloma),!  less  so  in  the  fibro-papilloma 

*  Mr.  R.  Harrison  (^I/dern.  Encyl.  Surg.,  vol.  vi.  p.  38)  states  that  in  the  Museum  of 
St.  George's  Hospital  there  is  a  specimen  of  a  villous  tumour  attached  to  the  neck  of 
the  bladder  of  a  gentleman  aged  81.  The  first  attack  of  haemorrhage  had  occurred 
twenty  years  before  death,  and  had  lasted  for  eight  months.  An  interval  of  four  years 
had  followed  this,  and  then  a  recurrence  of  haemorrhage,  which  ultimately  proved 
fatal.  Sir  B.  Brodie  also  states  that  the  disease  occasionally  extends  over  seven  or  eight 
years.  In  a  case  of  the  late  Mr.  W.  Anderson's  (6V?w.  Soc.  Trans.,  vol.  xviii.  p.  313).  of 
papilloma,  the  first  hematuria  had  taken  place  twelve  years  before,  then  came  an 
interval  of  a  year,  followed  by  recurrence  of  the  haematuria,  the  next  interval  being 
shortened  to  six  months,  after  which  recurrence  took  place  fairly  regularly  every  three 
months. 

t  The  following  classification  is  that  given  by  Prof.  Kilster  in  Volkniauu's  Clinical 
Lectures : — A.  New  growths  of  the  prostate — i.  Fibro-adenoma ;  2.  Myxoma ;  3.  Car- 
cinoma.    B.  New  growths  of  the  bladder — i.  New  growths  from  the  mucous  or  sub- 


376  OPERATIONS  ON  THE  ABDOMEN. 

or  in  the  "transitional"  growths.  Sir  H.  Thompson  lays  much  stress 
oil  the  fact  that,  in  these  cases,  the  stream  often  begins  without  any  or 
with  little  blood,  and  ends  of  a  bright-red  colour.  Again,  if  the  bladder 
b;"  washed  out  with  an  antiseptic  lotion  (p.  401),  this  becomes  deeply 
coloured  after  a  momentary  stay  within  the  viscus. 

II.  Sounding. — This  is  usually  said  to  be  negative,  but  it  should  be 
made  use  of  thoroughly  and  carefully.  In  the  case  of  a  single,  fimbriated 
})apilloma,  the  sound  may  give  no  information  unless  it  happen  to  detach 
a  portion  of  the  growth.  In  more  solid  growths — e.g..  a  fibrous  papilloma, 
a  transitional  or  sarcomatous  tumour — irregularity  or  resistance  may 
often  be  met  with  at  one  spot  in  moving  the  sound.  For  instance,  it 
may  be  easy  to  explore  one  side  of  the  bladder  by  carrying  the  sound 
over  to  the  opposite  thigh,  while  similar  manoeuvres  to  examine  the  other 
side  are  interfered  with.  In  the  mucous  polypi  of  children  an}'  move- 
ments of  the  sound  may  be  prevented,  and  carcinomata,  if  ulcerated, 
may  give  a  very  distinct,  uneven,  rugged  feel,  while  the  increase  of  pain 
afterwards  is  here  very  marked.  But  sounding  is  of  value  beyond  what 
it  tells  at  the  time.  By  iTsing  the  sound  with  judicious  and  gentle 
vigour,  particles  of  a  villous  groAvth  may  be  detached  for  microscopical 
examination.  This  may  perhaps  be  aided  by  washing  out  with  a 
lithotrity-evacuator,  as  suggested  by  Mr.  Davies-Colley.  Several  sur 
geons,  I  amongst  the  number,  have  had  cases  in  which  a  catheter  with  a 
large  eye  has  entangled  and  detached,  as  the  bladder  emptied,  processes 
of  the  growth.  Additional  knowledge  may  be  gained  by  the  sensation 
sometimes  given  by  the  catheter  as  if  it  were  moving  against  wet  wool 
or  sponge,  or  through  delicate  seaweed.  Every  precaution  must  be 
taken  not  to  cause  cystitis  or  to  set  up  bleeding  by  the  use  of  the 
catheter.  If  the  latter  follow,  the  bladder  should  be  opened  without 
delay.  M.  Guyon  (Ann.  de  Mai.  des  Org.  Gen.-Urin.,  1889,  p.  449)  points 
out  that  in  a  few  cases  a  pedunculated  growth  situated  near  "the  neck 
may  cause  obstruction  and  other  micturition  troubles,  before  hasmorrhage 
appears. 

III.  Examination  of  Urine. — This  aid  has  been  too  much  neglected 
because  the  natux-ally  present  "transitional"  epithelium  of  the  bladder 
maj^  so  easily  be  mistaken  for  growth  cells.  But,  in  the  case  of  villous 
growths  especiall}^,  careful  examination  of  the  urine  should  be  frecjuently 
made,  and  the  patients  directed  to  bring,  at  once,  any  white  or  shreddy 
particles  passed.  The  sediment  of  the  urine  should  be  also  frequently 
examined  microscopically  after  sounding  and  washing  out  the  bladder. 
The  delicate  papillae,  with  their  connective-tissue  basis  supporting  hosts 
of  columnar  cells  with  large  delicate  capillaries,  are  most  characteristic. 

IV.  TJte  Ci/stoscope. — In  certain  obscvire  cases,  as  where  a  growth  is 
present  for  some  time  without  causing  bleeding,  this  instrument  will  be 
of  much  service.  But  it  must  not  be  forgotten  that  its  use  entails 
certain  disadvantages.  Thus,  very  easy  to  use  in  the  bladder  of  women, 
in  men  it  is  a  ver}-  different  matter.     Here,  in  the  deep  urethra,  it  may 

mucous  coat  i.  Pai)illoma  (including  the  two  A'aricties  of  Sir  H.  Thompson),  viz.  : 
(a)  Fibriated  papilloma  or  villous  growth  ;  (/3)  fibro-papilloma.  Sir  H.  Thompson 
has  also  des^i-ibed  a  transitional  form  of  papilloma,  characterised  by  vascularity  and 
cell-infiltration.  2.  Fibrous  polypi  and  myxoma  ;  3.  Sarcoma,  ii.  New  growths  from 
rnc  muscular  coat :  4.  Myoma,  iii.  New  growths  from  the  epithelial  and  glandular 
tissues:  5.  Adenoma.     6.  Carcinoma.     7.  Dermoid  cyst. 


EEMOVAL   OF  GROWTHS  OF  THE  BLADDEE.  377 

excite  bleeding,  or  it  may  cause  grave  febrile  disturbance  ;  one  case  has 
been  related  to  me.  in  which  difficult}'  of  manipulating  it  through  the 
prostatic  urethra  was  followed  by  fatal  injury  to  this  part.  Such  cases 
are  not  published. 

Y.  Cystotomy. — The  cystoscope  can  help  us  as  to  the  size  and  site  of 
the  growth — but  whether  it  is  simple  or  malignant,*  whether  it  is 
merely  implanted  on  the  mucous  membrane  or  infiltrating,  can  onh' 
be  told  by  cystotomy,  and  not  always  by  this.  I  strongly  advise  a  more 
extended  use  of  supra-pubic  cystotomy  to  explore  and  clear  up  the 
diagnosis  in  these  cases.  Where  nothing  further  is  done  much  of  the 
risk  of  the  operation  will  be  removed  by  immediate  suture  of  the  bladder, 
which  will  admit  of  antiseptic  precautions  being  thoroughly  carried  out. 

VI.  Dilatation  of  Urethra. — This  should  always  be  made  use  of  in  a 
female  patient.  It  is  invaluable  in  clearing  up  the  case,  and  the 
incontinence  left  is  slight  and  of  brief  duration.  Uxi'loration  by 
ptringeal  incision.  This,  if  the  perinseum  is  not  very  deep,  the  prostate 
not  much  enlarged,  and  if  the  growth  is  not  very  far  from  the  neck  of 
the  bladder,-|-  may  give  useful  information,  but  it  is  not,  in  my  opinion, 
equal  to  opening  the  bladder  above  the  pubes  and  closing  the  incision 
by  suture,  if  nothing  more  is  done.  The  supra-pubic  incision  is  to  be 
advised  in  every  case.  The  vaginal  incision  again,  or  colpo-cystotomy 
is  not  to  be  relied  upon  for  sufficient  room :  moreover,  if  the  edges  are 
bruised,  it  runs  the  risk  of  leaving  the  patient  with  a  most  odious  fistula. 

YII.  Exclusion  of  other  Co7iditions — e.g.,  stone,  tubercular  and  other 
forms  of  cystitis,  also  hfemorrhage  from  the  prostate  or  kidney.  In 
none  of  these  cases,  save  in  the  last,  is  there  the  spontaneous  character 
which  often  marks  the  bleeding  of  bladder  growths.  In  renal 
hsematuria  due  to  growth  the  bleeding  may  be  spontaneous,  and 
unaccompanied  by  other  evidence.  Here  the  renal  region  should  be 
thoroughly  examined  at  regular  intervals.  In  tubercular  disease  of  the 
bladder  the  bleeding  is  never  as  severe  as  in  growth,  and  for  a  long  time 
occurs  with  the  end  of  micturition.  Other  evidence  ^^■ill  also  be 
present,  and  so  too  with  the  liEemorrhage  of  enlarged  prostate,  which 
will  ver}'  likely  be  preceded  by  a  chill  or  by  retention. 

Indications  for  Operation. — Growths  of  the  bladder  being  in- 
evitably fatal,  whether  from  haemorrhage,  or  pain,  or  the  results  of 
obstruction,  or  from  these  combined,  the  surgeon  is  entirely  justified 
in  urging  an  early  digital  exploration  to  clear  up  the  case  and  the 
question  of  removal.  This  may  be  supra-pubic  cystotomy,  with 
immediate  suture  if  nothing  more  is  done,  or  dilatation  of  the 
urethra  in  a  female  subject.  While  it  remains  as  yet  uncertain 
how  many  of  the  cases  published  as  cures  are  really  and  permanently 
so,  even  in  the  case  of  the  villous  growth,  it  is  an  undoubted 
fact  that  an  operation  may  result  in  arresting  the  haemorrhage  com- 
pletely for  years.     In  other  cases,  haemorrhage,  pain,  and  frequency  of 

*  It  is  always  worth  while  to  remember  the  vast  preponderance  of  malignant  over 
benign  growths  of  the  bladder  (Wallace,  Edin.  Med.  Jonrn.,  1893,  p.  735).  Thus,  out  of 
eighty-eight  cases  which  Albarran  personally  examined,  sevonty-one  were  malignant 
and  seventeen  simple.    Out  of  twenty-two  cases  Guyon  found  nineteen  to  be  malignant. 

t  If  the  growth  be  a  very  soft  one  it  will  be  found  very  difficult  to  determine  by  the 
perin?eal  route  which  is  growth  and  which  is  bladder.  By  the  supra-pubic  opening 
the  eve  will  determine  this. 


378  OPERATIONS  ON  THE  ABDOMEN. 

micturition  may  all  be  very  largely  relieved.  Where  little  or  nothing 
can  be  done  in  the  way  of  removal,  the  free  escape  given  to  the  urine 
by  a  perinteal  or  supra-pubic  operation  or  by  dilating  the  neck  of  the 
bladder  in  a  woman  may  give  great  relief;  where  even  this  fails,  the 
diagnosis  has,  at  least,  been  cleared  up. 

If  in  doubt  as  to  recommending  exploration,  the  practitioner  should 
remember:  (i)  That  the  long  intervals  l)etween  the  bleedings  teach 
strongly  that  growths  of  the  bladder  often  pass  through  a  long  first 
stage,  during  which  the  growth  is  connected  with  the  mucous  membrane 
only  ;  (2)  That,  following  on  the  above,  infiltration  of  the  deeper  coats, 
and  thus  glandular  infection,  is  often  here  long  delayed.  While  the 
long  intervals  between  the  bleedings,  and  the  comparative  slightness  of 
the  other  symptoms,  may  make  the  surgeon  unwilling  to  urge  operative 
interference,  it  is  right  that  it  should  be  ver}"  clearly  put  before  the 
patient  that  it  is  in  this  stage  only  that  any  hope  of  a  radical  cure  can 
be  given,  and  that  later  on,  when  the  stage  of  infiltration  is  reached, 
not  onh"  is  radical  cure  almost  out  of  the  question,  but  the  risk  of 
attempting  it  and  so  of  perforating  the  coats  is  vastl}"  increased.  The 
points  that  a  supra-pubic  exploration  will  clear  up  about  the  gro\\i;h 
are  the  number,  site,  whether  accessible  or  not,  and  its  relation  to  the 
ureter,  how  far  pedunculated  or  sessile,  liow  far  it  seems  attached  to  the 
coats  of  the  bladder.  There  is  a  general  belief,  I  think,  that  peduncu- 
lated growths  are  usually  benign.  This  is  a  very  dangerous  belief. 
Malignant  growths  or  transitional  ones  becoming  malignant  form  the 
very  great  majority  of  bladder  growths.  If  the  growth  is  at  all  thick 
or  succulent,  if  it  is  at  all  infiltrating — i.e.,  not  a  merely  implanted 
pedicle — the  odds  are  greatly  in  favour  of  recurrence,  however 
thorough!}*  the  growth  is  removed.  Of  twenty-eight  cases  of  peduncu- 
lated growths  examined  by  Albarran  fifteen  were  malignant.  In 
apparently  simple  cases  recurrence  may  take  place  in  spite  of  the  most 
complete  operation  {{hid.).  The  more  the  growth  approximates  the 
worst  of  all  types  of  bladder  growth — viz.,  the  low-lying,  broad-based, 
fixed,  sessile  lump,  especialh'  if  with  a  sloughy  surface  incrusted  with 
phosphatic  debris,  the  more  hopeless  is  operative  interference. 

Choice  of  Operation. — In  ni}'  opinion,  in  all  cases,  but  especially 
where  the  surgeon  is  uncertain  as  to  the  size  or  the  number  of  growths, 
where  the  perinteuni  is  xevy  deep,  where  the  prostate  is  enlarged,  or 
the  perinoeum  small  and  the  pelvic  outlet  contracted,  the  supra-pubic 
method  will  be  safest  and  give  most  room.  So,  too,  in  the  case  of  a 
recurrent  growtli,  this  method  should  be  employed,  as  it  cannot  be  told 
how  far  the  recurrence  is  widely  diffused.  The  supra-pubic  operation 
is  always  to  be  preferred  as  enabling  one  to  see  as  well  as  to  touch  the 
growth,  as  alone  giving  more  room  for  necessary  manipulations,  e.g., 
the  use  of  an  electric  lamp  in  what  may  be  a  very  difficult  operation.* 

Only  when  there  is  strong  reason  to  believe  that  the  growth  is  single, 
or  small,  and  near  the  neck,  ma}-  the  bladder  be  explored  from  the 
perinaeum  by  opening  the  membranous  urethra,  and  dilating  the  vesical 
neck.     But  even  here  I  do  not  recommend  it. 


*  It  is  noteworthy  that  all  the  surgeons  of  widest  experience  have  declared 
for  the  supra-pubic  method — viz.,  Sir  H.  Thompson,  Guyon,  Yolkmann,  Dittel,  von 
Antal,  &c. 


REMOVAL  OF  GROWTHS   OF  THE  BLADDER.  379 

In  some  Ccases  it  will  be  advisable  to  combine  both  operations,  as  the 
perinaeal  opening  enables  the  siirgeon  to  nse  two  index-fingers  in  the 
bladder  at  the  same  time,  and  also  favours  drainage,  especialh^  where 
the  urine  is  foul. 

In  cases  where,  owing  to  complete  removal  having  been  an  impossi- 
bility, it  is  desu-ed  to  give  relief  by  a  permanent  opening,  a  supra-pubic 
one  kept  patent  by  a  short  curved  tube  and  plate  (somewhat  like  a 
tracheotomy-tube)  will  be  preferable  to  a  perinasal  opening,  owing  to 
the  tendency  of  the  latter  to  close. 

Operation. — -If  the  surgeon  decide  to  first  open  the  membranous 
urethra  for  purposes  of  exploration  or  to  ensure  drainage  he  does  so  in 
the  manner  of  a  median  lithotomy  (p.  406).  and  explores  the  bladder 
after  dilating  the  neck  with  his  finger,  which  is  made  to  enter  by 
a  careful  insinuating  movement  along  the  director,  which  is  then 
withdrawn.  If  no  growth  is  felt  near  the  neck,  the  surgeon,  rising, 
makes  firm  supra-pubic  pressure,  so  as  to  bring  the  upper  part  of  the 
bladder  into  contact  with  his  left  index. 

Usually  the  surgeon  determines  to  make  a  supra-pubic  opening  at 
once,  for  the  reasons  already  given.  In  order  to  secure  the  maximum 
elevation  of  the  base  of  the  "bladder  a  rectal  bag  (p.  400)  should  be  used 
here.  The  bladder  is  then  distended,  either  through  the  penis,  or 
through  the  perinseal  wound  by  a  large  catheter,  this  wound  being 
finally  plugged  around  the  catheter  with  iodoform  gauze,  aided,  if 
needful,  by  digital  pressure  exerted  by  an  assistant.  The  supra-pubic 
opening  is  then  made  with  the  precautions  given  at  p.  402  ;  when  the 
bladder  is  distinctly  reached,  some  advise  that  one  or  two  sutures  of 
carbolised  silk  be  jDassed  across  the  site  of  the  intended  opening  into 
the  bladder  with  a  curved  needle  in  a  handle.  The  opening  into  the 
bladder  is  then  made  (carefully,  so  as  not  to  divide  the  undei'h'ing  silk), 
and  the  silk  is  hooked  up  and  divided ;  by  this  means  two  or  four 
sutures  are  present,  which  will  serve  to  raise  up  the  bladder  as  required, 
and  to  keep  it  well  open  and  within  reach  during  the  manipulations 
required  for  the  removal  of  the  tumour.*  I  prefer  the  use  of  two 
Spencer  Wells's  forceps  on  either  lip  of  the  wound,  held  by  assistants ; 
the  threads  when  pulled  upon  being  liable  to  tear  the  delicate  tissue 
of  the  bladder.  The  slight  bruising  inflicted  by  the  forceps  is  not  of 
importance,  as  all  the  opening  will  not  be  sutiired. 

In  opening  out  and  exposing  the  cavity  of  the  bladder  speculaj  of 
wire  (solid-bladed  ones  taking  up  too  much  room)  will  be  found  very 
useful,  but  the  need  of  these  and  other  rarely  used  and  expensive  instru- 
ments will  be  less   felt  if  an  electric  lamp  is  at  hand. 

The  removal  of  the  growth  is  effected  in  different  ways,  according  to 
its  structure.  Sharp  spoons,  curettes,  appropriate  forceps,  straight,  and 
of  different  curves  (Fig.  158),  Jessop's  prostatectomy  forceps,  those  with 


*  In  difficult  cases  the  position  of  Treudelenberg  (p.  387)  is  always  to  be  employed. 
The  intestines  gravitating  towards  the  diaphragm  drag  upwards  the  peritonteum  and 
thus  the  bladder  slightly.  The  deeper  parts  of  the  viscus  can  now  be  better  brought 
into  view,  especially  with  an  electric  lamp. 

t  Of  these  special  instruments  the  bladder-speculum  with  two  wire  blades  invented 
by  Watson  of  Boston  (^Lancet,  Oct.  18,  1890)  and  the  three-jawed  speculum  of  Bruce 
Clarke  QBrit.  Med.  Jintrn..  July  4,  iSgi)  are  the  best. 


38o 


OPERATIONS  OX  THE  ABDOMEX. 


serrated  blades  introduced  by  Sir  H.  Thompson,  Paquelin's  cautery,  and 
a  small  ecraseur  with  a  violin-string  ligatiire,  should  be  at  hand/^ 
When  a  growth  has  a  sufficiently  long  pedicle,  it  should  be  dragged  up 
and  twisted  or  cut  away  a  little  above  its  attachment  to  the  mucous 
membrane.  This  and  the  adjacent  mucous  membrane  f  must  then  be 
deliberately  removed  with  blunt-pointed  scissors.  If  the  cut  edges  can 
be  united  iW  catgut  sutures,  so  much  the  better ;  if  not,  the  wound  must 
be  left  to  granulate. 

In  more  doubtful  cases — cases  transitional  between  innocent  and 
malignant — the  following  test  of  Albarran's  may  be  useful :  "  The 
gliding  or  otherwise  of  the  mucous  membrane  ought  to  regulate  the 
depth  of  the  removal  of  the  growth ;  wherever  the  mucous  membrane 
seems  fixed  to  the  sub-mucous  coat  it  would  be  better,  even  in  pedim- 
culated  growths,  to  resect  the  entire  wall,  a  step  still  more  essential  in 
small  sessile  tumours "  {vide  infra,  Partial  Hesection  of  the  Bladder, 


Fig.   i=;8 


Useful  forceps  for  twisting  away  of  bladder  growths  or  bypertrophied 
prostate  tissue.  (R.  Harrison.] 

(P-  383)-  When  the  growth  is  of  firmer  consistence  and  more  of  the 
sessile  type,  it  should  be  clipped  away  with  scissors,  punched  out  (if  firm) 
bit  by  bit  with  Jessop's  prostatectomy  forceps,  scraped  down  with  the 
nail  or  curette,  or  partly  nibbled,  partly  twisted  out,  by  Sir  H.  Thompson's 
serrated  forceps. |     This  surgeon  thus  describes  the  use  of  the  forceps  : 


*  The  galvanic  Ecraseur  should  never  be  used  unless  other  instruments  have  failed. 
The  loop  wiU,  no  doubt,  shear  away,  without  haemorrhage,  large  masses  which,  from 
their  size,  poorly  marked  pedicles,  and  vascularity,  are  very  difficult  to  deal  with 
otherwise.  But  its  liability  to  introduce  septic  complications,  and  the  difficulty  of 
manipulation  in  a  deep  contracted  space,  are  grave  objections  to  the  cautery.  If  the 
surgeon  is  driven  to  use  an  Ecraseur,  he  should  employ  the  ordinary  wire  one,  on 
account  of  the  above-mentioned  septic  complications.  Mr.  Bryant  (^Lancet,  1886, 
vol.  ii.  p.  1076)  found  the  following  method  useful  in  the  case  of  a  bladder  which 
appeared  to  be  filled  with  villous  growth:  A  great  deal  having  been  removed  by 
forceps,  the  bladder  was  scraped  throughout,  the  walls  being  wiped  rather  roughly 
■with  a  new  sponge  tightly  tied  round  a  forceps.  Haemorrhage  recurred  six  months 
later,  persisting  for  a  week  ;  it  then  stopped,  and  the  man  was  doing  well  eighteen 
months  after  the  operation.  Used  in  a  similar  case  this  method  has  been  inefficient 
and  followed  by  rapid  recurrence. 

f  '■  Even  in  the  most  simple  cases  the  removal  of  the  growth  should  be  more  exten- 
sively performed  than  is  the  custom,  and  all  the  mucous  membrane  in  contact  with 
the  growth  should  be  removed.  We  have  seen  the  possibility  of  infection  by  contact 
with  the  mucous  membrane,  and  the  plan  I  propose  is  to  eradicate  the  epithelial 
neoplasms  that  may  exist  around  the  growth,"  Albarran  (Jioc.  supra  cit.'). 

X  AVhatever  method  is  used,  the  surface  left  should  be  as  smooth  as  possible,  in  order 
to  diminish  the  risk  of  phosphatic  deposit. 


REMOVAL  OF  GEOWTHS  OF  THE  BLADDER.       38 1 

Ha^'ing,  with  liis  forefinger,  first  made  himself  familiar  with  the  exact 
position  and  size  of  the  tumour,  the  surgeon  inserts  the  forceps,  guided 
only  by  the  knowledge  thus  acc[uired,  and  makes  a  decided  snip  on  the 
Tumour ;  then,  b}'  moving  the  forceps  in  diiferent  directions,  he  makes 
.sure  that  he  has  the  growth  within  their  grasp.  "  Above  all  things,  he  is 
not  to  pull  forcibh',  but  to  press  firmly  the  blades  together,  biting  or 
chewing  a  little,  if  I  may  use  the  terms,  with  the  extremities  of  the 
blades  without  changing  the  original  situation  of  the  bite  or  grasp. 
Then  a  little  twisting  movement  ma}*  help  to  di.sengage  the  mass,  which, 
if  accomplished,  the  forceps  will  be  felt  free,  and  may  be  withdrawn  with 
their  contents,  after  which  the  finger  enters  to  feel  what  remains  and 
what  more  must  be  done  in  order  to  complete  the  removal.  Let  me 
remark,  whenever  the  forceps  has  removed  a  portion,  however  small, 
the  instrument  should  never  be  reintroduced  until  the  finger  has  again 
examined  the  interior"  (Brit.  Med.  Joicni.,  1884,  vol.  i.  p.  1240; 
Tumours  of  the  Bladder,  p.  80). 

The  same  surgeon  thus  draws  attention  to  the  great  risk  of  making 
strong  supra-pubic  pressure  while  forceps  are  being  used  through  a 
perineal  wound  :  "If  that  pressure  is  considerable,  it  forces  the  upper 
wall  of  the  bladder  into  its  own  cavity,  and  thus  gives  the  growths  a 
larger  contour  than  they  possess,  and  makes  them  apparently  salient  to 
a  much  greater  extent  than  they  really  are.  Thus,  an  eager  or  in- 
experienced operator,  unaware  of  the  effects  of  strong  supra-pubic 
pressure,  might  be  led  to  seize  the  mass  offered  to  the  forceps  through 
the  influence  of  this  pressure,  and,  under  the  belief  that  it  was  a  large 
gro^^i;h,  he  might  inflict  a  fatal  wound  by  crushing  a  double  fold  of  the 
coats  of  the  bladder,  and  so  make  an  opening  in  the  peritona?um.  To 
avoid  such  a  catastrophe,  it  is  only  necessary,  first,  to  decline  the 
attempt  to  destroy  any  growth  which  is  clearly  not  sufficiently  salient 
to  admit  of  complete  or  nearly  complete  removal ;  and,  secondly,  never 
to  employ  the  forceps  while  forcible  supra-pubic  pressure  is  made — at 
least,  no  more  pressure  than  is  desirable  just  to  steady  and  support  the 
bladder  and  the  parts  adjacent." 

When  the  mass  of  the  growth  has  been  removed  by  the  nail,  curette. 
or  twisting-forceps,  the  base  must  be  destroyed  as  effectually  as  possible 
by  Paquelin"s  cautery,*  or  partial  resection  must  be  performed.  Quiet 
nibbling  and  careful  torsion  will  remove  the  bulk  of  the  attachment  of 
the  growth,  but  if  we  are  to  progress  in  our  surgery  here,  a  radical  cure 
can  only  be  hoped  for  in  growths  that  infiltrate  the  bladder  wall  bv 
treating  them  as  we  do  malignant  disease  elsewhere — i.e.,  operating 
early  and  removing  the  whole  thickness  of  the  tissues  affected,  as  long 
as  this  step  is  not  foolhardy  (see  Partial  Eesection,  p.  383).  Finallv, 
two  Avarnings  of  Mr.  Fenwick's  must  be  remembered  by  those  who 
trust  to  forceps  and  nibbling  or  twisting.  "  Munching  the  surface 
of  a  carcinoma  and  leaving  the  base  is  tantamount  to  an  increase  in 
the  rapidity  of  its  growth.  I  have  reason  to  believe  that  the  munching 
or  squeezing  of  the  healthy  mucous  membrane  in  the  neighbourhood 
of  the  growth  fosters  the  appearance  subsequently  of  growth  in  the 
traumatised  areas"  (Brit.  Med.  Journ.,  1895,  "^'ob  ii-  P-  906). 

*  Though  this  method  has  the  sanction  of  M.  Guyon,  it  is  only  to  be  used  in  the  case 
of  large  growths  where  partial  resection  is  out  of  the  question.  Besides  the  inherent 
risk  of  sepsis  it  leaves  a  wound  slow  in  healing,  and  a  source  of  obstinate  cystitis. 


382  OPERATIONS  OX  THE  -ABDOMEX. 

Hsemorrhage. — This  must  be  met  by  sponge-pressure,  occasional!}" 
ligatm-e,  or  washing  out  with  mercury  perchloride  solution,  I  in  6000, 
at  a  temperature  unpleasantly  hot  for  the  hand.  If  it  persists  in  spite 
of  the  above,  and  if  the  bleeding  point  is  on  the  floor  or  above  the 
neck,  gauze  tamponnading  must  be  employed. 

Two  American  surgeons,  Dr.  Keyes  and  Dr.  Cabot,  have  made  use  of 
this  successfull}^  (Med.  Bevieiu,  Sept.  17,  1892).  Bichloride  gauze  is  cut 
into  pieces,  some  twenty  in  number,  these  having  sides  six  inches  long 
on  one  aspect,  three  on  the  other,  and  four  inches  in  the  middle.  In 
the  centre  of  the  three-inch,  a  small  white  shirt-button  is  attached, 
which  securely  transfixes  the  tampon,  and  has  a  long  double  piece  of 
silk  running  away  on  the  six-inch  surface  and  a  single  piece  on  the 
three-inch  one ;  a  piece  of  silk  is  also  attached  to  each  of  the  four 
corners.  The  tampon  is  introduced  thus  :  a  soft  catheter  is  passed  into 
the  bladder  and  out  through  the  supra-pubic  wound.  The  loop  of 
double  silk  is  then  tied  on  to  its  end  and  thus  drawn  out  at  the  meatus. 
The  catheter  being  removed,  traction  on  the  silk  draws  the  gauze  down 
on  to  the  bleeding  surface,  and  the  double  silk  loop  is  then  tied  at  the 
meatus  over  a  piece  of  gauze.  If  there  be  a  perinteal  wound,  the  silk  is 
drawn  through  these  incisions  and  tied  tightly  over  a  gauze  perin^eal 
pad.  The  removal  of  the  tampon  is  efiected  by  cutting  the  knotted 
silk  and  pulling  on  the  five  other  pieces,  the  encts  of  which  have  been 
brought  out  of  the  supra-pubic  wound. 

When  the  operation  is  completed  the  question  will  arise  as  to  the 
advisability  of  suturing  the  bladder.  In  the  after-treatment  of  all 
supra-pubic  cystotomies,  the  chief  nuisance,  and  a  very  great  one,  is 
constant  soakage  of  the  dressings  by  the  urine.  This  should  be  avoided 
whenever  the  following  conditions  make  the  use  of  sutures  safe, 
(i)  Efficient  suturing,  ^\■ith  silk  or  catgut.  If  the  mucous  membrane 
be  stitched,  a  continuous  suture  of  catgut  must  be  employed,  and  a 
row  of  Lembert's  sutures  externally  taking  up  the  muscular  coat  only. 
(2)  Efficient  emptying  of  the  bladder.  (3)  Arrest  of  bleeding,  other- 
wise the  catheter  will  be  blocked,  the  distress  great,  and  much  tension 
will  be  thrown  on  the  stitches.  (4)  An  aseptic  condition  of  the  urine. 
(5)  An  operation  in  which  the  manipulations  have  not  been  very  pro- 
longed and  difficult,  and  one  especially  in  which  there  has  not  been 
much  disturbance  of  the  cavum  Retzii.  If  the  surgeon  is  wisely 
cautious  about  suturing  the  whole  of  the  bladder  wound,  he  will 
suture  it  almost  completely,  and  leave  in  a  small  drainage-tube,  putting 
in  one  or  two  provisional  sutures  which  he  will  tighten  up  in  a  few 
days,  when  the  risk  of  haemorrhage  and  extravasation  has  passed  away. 
When  the  conditions  given  above  are  not  present,  and  suturing  the 
bladder  involves  too  much  risk,  the  cut  edges  of  the  bladder  should  be 
united  to  those  of  the  lower  part  of  the  parietal  wound  with  catgut, 
and  an  india-rubber  catheter,  lengthened  by  a  piece  of  drainage  tube, 
passed  along  the  urethra,  and  out  at  the  supra-pubic  wound.  Several 
holes  should  be  cut  in  the  part  that  is  to  lie  within  the  bladder. 
Bringing  the  tube  out  above  the  pubes  facilitates  washing  out  the 
bladder  both  ways. 

If  a  catheter  thus  inserted  does  not  drain,  the  only  way  to  save 
the  patient  from  the  annoyance  and  risk  of  constant  soakage  of  urine  is 
to  employ  syphonage,  a  method  more  easily  written  of  than  efficiently 


EEMO^"AL  OF  GROWTHS  OF  THE  BLADDER.  383 

secured.*  Or  a  trial  may  be  made  of  placing  fine  catheters  within  the 
ureters  and  bringing  these  out,  inside  tubes,  through  the  supra-pubic 
wound. -f* 

Partial  Resection  of  the  Bladder  for  CtroidJis. — A  few  cases  have  been 
recorded  with  a  sufficient  amount  of  success  to  justify  a  repetition  of  the 
operation  in  selected  cases.  The  growth  must  be  situated  somewhere  in 
the  upper  or  middle  zones  of  the  bladder.  In  cases  where  the  gro\vth 
is  near  the  hasfond.  or  in  the  vicinity  of  the  ureter,  resection  is  out  of 
the  question,  and  we  must  be  content  with  careful  erasion,  with  or 
without  cauterisation  at  a  red  heat.  Where  the  vertex  or  neighbour- 
jiood  is  the  seat  of  the  growth  Antals  extra-peritonaeal  method  should 
be  followed.  By  this  a  large  amount  of  the  iipper  part  of  the  bladder 
may  be  removed,  but  the  farther  the  resection  is  carried  the  greater  is 
the  difficulty  of  stripping  off  the  pei-itonteum,  and,  of  course,  in  closing 
the  gap. 

The  peritonfEum  is  much  more  easily  peeled  off  when  the  bladder  is 
full  than  when  it  is  empty.  The  edges  of  the  Avound  in  the  bladder 
should  be  closed  with  silk  sutures  as  completely  as  possible.  When  the 
resection  has  been  so  complete  that  the  gap  cannot  be  closed,  its  edges 
must  be  united  to  those  of  the  parietal  wound,  and  the  opening  closed 
later  on  by  a  plastic  operation. 

A  good  account  of  a  case  of  resection  of  part  of  the  lateral  wall  and 
disease  of  the  bladder  is  given  by  Mr.  H.  Fenwick  (Clin.  Soc.  Trans., 
vol.  xxvii.  p.  164)  : 

The  patient  was  a  man  aged  46.  The  growth,  an  epithelioma,  had  been  removed 
twice  before,  the  first  time  by  the  perinjeal  route,  the  second  time  supra-pubically. 
from  a  spot  to  the  left  of  the  orifice  of  the  left  ureter.  "  On  opening  the  bladder 
supra-pubically,  the  growth  was  found  to  have  recurred  in  the  scar  of  the  previous 
operation.  It  was  now  a  smooth,  sessile  epithelioma,  one  inch  and  a  half  by  one  inch. 
The  base  was  indurated,  and  the  infiltration  had  involved  the  muscular  and  sub-mucous 
layers,  for  they  were  glued  to  the  tumour.  In  order  to  gain  free  access  to  the  left 
lateral  wall  of  the  bladder,  I  drew  my  knife  horizontally  through  the  left  lower 
abdominal  muscles,  the  incision  commencing  at  the  supra-pubic  opening,  and  ending 
at  a  point  above  the  inner  third  of  Poupart's  ligament.  Stripping  off  the  peritonieum 
from  the  front  wall  of  the  left  pelvis,  I  kept  it  packed  up  with  sponges.  I  then  re- 
sected the  growth  by  cutting  away  with  scissors  it  and  the  entire  thickness  of  that 

*  The  best  means  of  draining  the  bladder  is  one  described  by  my  friend  Jlr.  Cathcart, 
of  Edinburgh  QBrit.  Med.  Jonrn.,  1895,  vol.  ii.  p.  968).  Besides  a  douche-can,  some 
india-rubber  tubing  and  a  pail,  a  screw-clamp,  a  small  glass  Y  or  T  tiabe.  a  second  piece 
of  glass  tubing  bent  like  a  capital  S.  and  a  third  piece  bent  at  a  right  angle  to  go  into 
the  bladder,  are  required.  The  can  filled  with  water  is  fixed  over  the  patient's  bed. 
the  Y  tube  is  fastened  with  a  large  safety-pin  to  the  edge  of  the  mattress  opposite  the 
patient's  pelvis.  To  one  limb  of  the  Y  tube  is  attached  about  a  foot  of  ttibing  which 
is  connected  with  the  can,  to  the  other  a  right-angled  glass  tube,  which  dips  into  the 
bladder.  To  the  stalk  of  the  Y  tube  a  third  bit  of  tubing  is  attached  which  is  fixed 
below  to  the  S  glass  tube,  which  by  means  of  another  bit  of  tubing  should  end  under 
some  aseptic  lotion.  The  apparatus  being  in  position,  the  screw-clamp  which  controls 
the  rubber  tubing  between  the  irrigator  and  one  arm  of  the  Y  tube  is  then  relaxed,  so 
as  to  allow  the  water  to  run  very  slowly,  in  fact,  only  hydrops.  It  accumulates  in  the 
S  tube,  and  as  it  tends  to  run  out  produces  a  negative  pressure  in  the  other  arm  of  the 
Y  tube — i.e..  the  one  connected  with  the  tube  in  the  bladder,  thus  withdrawing  the 
urine. 

t  Schede  has  thus  kept  a  tube-catheter  in  one  ureter  for  several  days  without  any 
harm  resulting. 


384  OPERATIONS  ON  THE  ABDOMEN. 

part  of  the  bladder  which  was  subjacent  to  it.  The  bladder  incision  commenced  at  the 
median  opening,  and  passed  directly  to  the  left  until  the  upper  margin  of  the  growth 
was  reached.  It  then  proceeded  round  the  tumour.  The  left  side  of  the  trigone  was 
almost  involved,  but  the  ureteral  orifice  was  not  encroached  upon.  The  haemorrhage 
was  not  severe  and  was  easily  controlled  by  a  couple  of  dozen  Spencer  AVells's  forceps." 
The  edges  of  the  bladder  wound  were  drawn  together  by  catgut  sutures  which  traversed 
only  the  muscular  layers,  a  small  supra-pubic  opening  being  left  for  drainage.  This 
wound  and  that  in  the  abdominal  wall  healed  quickly,  and  two  j^ears  later  {Brit.  Med. 
Journ..  1895,  vol.  ii.  p.  907)  Mr.  Fenwick  stated  that  the  patient  was  at  work  in  good 
health. 

All  will  agree  with  the  three  conditions  which  Mr.  Fenwick  considers 
necessar}^  before  such  operations  are  undertaken  :  (i)  A  single  growth, 
slow  and  dense.  (2)  Absence  of  cystitis.  (3)  Sufficient  vis  on  the  part 
of  the  patient  to  bear  so  serious  an  operation. 

If  it  is  decided  to  attempt  intra-peritonseal  resection,  as  of  a  portion  of 
the  lower  part  of  the  bladder,  the  following  directions  of  Albarran  may  be 
useful.  A  preliminary  partial  resection  of  the  sjniiphysis  as  advised  by 
Helferich  is  first  performed.  The  recti  and  pyramidales  are  detached 
above,  and  the  external  obturators  below  and  externally ;  the  periosteum 
is  then  carefully  reflected,  and  sufficient  of  the  bone  removed  by  an 
osteotome  and  cutting  forceps  to  expose  the  lower  part  of  the  bladder.* 
The  bladder  having  been  freely  opened  in  front,  and  the  escaping  urine 
carefully  removed  with  gauze  sponges,  the  peritonseal  sac  is  opened,  and 
the  intestines  carefulh^  packed  away  with  sponges.  We  wdll  suppose 
that  it  is  decided  to  resect  part  of  the  trigone  and  bas-fond  comprising 
one  ureter.  A  bougie  is  passed  into  the  ureter,  the  part  to  be  removed 
is  taken  away  from  within,  a  hand  introduced  into  the  peritonseal  sac 
and  behind  the  bladder,  keeping  touch  of  the  catheterised  ureter  and 
guiding  the  scissors.  A  stitch  is  then  passed  through  the  ureter  so  that 
it  can  be  easily  pulled  up  and  cut  across  where  desired.  Sutures  are 
then  passed  across  the  lower  vesical  wound,  and  some  having  been  tied, 
a  hole  is  made  in  the  posterior  wall  of  the  bladder,  the  ureter  is  pulled 
through,  split  longitudinally  for  a  short  distance,  and  its  mucous  mem- 
brane sutured  to  that  of  the  bladder.  If  possible,  one  or  two  sutures 
are  put  in  from  outside  to  strengthen  the  point  of  junction.  When  this 
is  made  complete  a  catheter  is  passed  into  the  iireter  and  brought  out 
through  a  tube  through  a  supra-pubic  wound.  The  bladder  wound  is 
closed  round  the  tube,  and  the  space  between  the  bladder  and  the  pubes 
is  kept  packed  with  iodoform  gauze. 

Gomijlete  ExtirjMtion  of  the  Bladder.f — This  operation  has  been  per- 
formed by  Bardenheuer  and  Gussenbauer.  The  first  successful  case 
was  by  Paulick  of  Prague.  Olado  has  had  a  second.  Both  of  these 
were  in  women.  In  each  case  the  operation  was  done  in  two  stages, 
the  ureters  being  first  diverted  to  and  secured  in  the  vagina,  and  then, 
about  three  weeks  later,  the  bladder  removed.  The  vagina  by  the 
second  operation  was  converted  into  a  pseudo-bladder.  Paulick's 
patient  was  alive  two  years  and  a  half  after  the  operation,  and  in 
fair    comfort.      Drs.  Tuffier   and  Dujarier  (Revue  de   Chiriirgie,   April 

*  This  step  gives  but  little  extra  room,  and  opens  up  cancellous  tissue  and  thus  fresh 
sources  of  septic  phlebitis. 

f  A  paper  by  M.  Chevalier  {Arch.  Gin.  dc  Med..,  t.  ii.  1894)  contains  much  infurn.a- 
tion  on  partial  and  complete  resection  of  the  bladder. 


OPERATIVE  INTERFERENCE  IN  TUBERCULAR  DISEASE.        385 

1898)  describe  a  successful  case  of  complete  extirpation  of  the  bladder 
in  a  man  in  one  operation,  the  ends  of  ureters  being  transplanted 
into  the  rectum.  Two  months  after  the  operation  the  man  was  able 
to  do  his  work. 

Causes  of  Death  after  Removal  of  Bladder  Tumours. 

I.  Shock.  Mr.  K.  Harrison  (Lancet,  1884,  vol.  ii.  p.  678J  records  a 
case  of  a  man,  aged  42,  who  died  somewhat  suddenly,  apparently 
from  shock,  twelve  hours  after  removal  of  a  villous  tumour  by  the 
perineeal  method.  The  hemorrhage,  which  had  begun  four  years 
before,  had  for  a  year  been  persistent  and  considerable.  Mr.  Harrison, 
in  illustration  of  the  sudden  and  excessive  bleeding  to  which  villous 
tumours  are  liable,  even  when  they  appear  comparatively  C|uiescent,  has 
published  {Liverpool  Med.-Chir.  Journ.,  Jul}^  1884)  a  case  where  death 
took  place  from  this  cause  in  nine  hours.  In  this  instance  slight 
hsematuria  had  existed  for  some  months  previously,  but  no  operation 
had  been  performed.  Mr.  Morton  has  drawn  attention  (Lancet,  1896, 
vol.  i.  p.  480)  to  the  possibility  of  secondar}"  haemorrhage.  In  his  case 
a  papilloma  had  been  removed  supra-pubically,  the  pedicle  being  cut 
through  with  scissors.  Severe  bleeding  took  place  on  the  third 
day,  necessitating  opening  up  the  wound.  The  patient  recovered. 
2.  Exhaustion.  3.  Cellulitis.  4.  Failure  of  the  kidneys.  Evidence 
of  this  will  of  course  be  sought  for  before.  It  is  most  likely  to  occur 
in  growths  which  from  their  position  have  obstructed  the  outflow  of 
urine.  5.  Injury  to  the  bladder  and  peritonitis.  Mr.  Brj-ant  (Lancet. 
1886.  vol.  ii.  p.  1077)  mentioned  a  case  in  which  a  fibrous  polypus  was 
drawn  from  the  fundus  into  the  perinatal  wound  and  snipped  off.  The 
man  died  of  peritonitis,  and  a  small  hole  was  found  in  the  bladder  at 
the  site  of  the  removed  polypus.  6.  Recurrence.  This  may  appear 
first  in  the  cicatrix  of  the  wound.  7.  Abscess  in  the  track  of  the 
apparently  healed  wound,  bui-sting  into  the  peritonseal  sac  (Sir  H. 
Thompson,   Clin.  Sac.  Trans.,  vol.  xxi.  p.  46). 


OPERATIVE    INTERFERENCE    IN    TUBERCULAR    DISEASE 
OF    THE    BLADDER. 

My  own  experience  in  several  of  these  cases  and  a  study  of  what 
others  have  published  leave  me  strongly  of  opinion  that  operative  inter- 
ference in  the  form  of  cystotomy  is  rarely  justifiable  here.  My  reason 
for  this  opinion  will  be  gathered  from  the  following  Indications  and 
Cautions,  (i)  It  is  an  accepted  fact  by  all  careful  surgeons  that  in 
tubercular  affections  in  which  it  is  not  possible  to  remove  the  mischief, 
operative  interference  may  do  more  harm  than  good.  Under  such 
conditions  the  manipulations  only  irritate  early  tubercle  into  activity, 
and  light  up  again  obsolete  or  quiescent  tubercle,  besides  causing 
certain  dangers*  peculiar  to  this  viscus — viz.,  cystitis  and  pyelitis. 
Again,  to  show  how  useless  and  even  harmful  will  be  operative  inter- 

*  Another  ill  result  ■which  is  very  possible  here  is  rupture  by  even  a  moderately 
distending  injection  of  a  contracted,  rigid  bladder  the  seat  of  long-standing  tuber- 
cular mischief,  and  one  emptied  for  some  time  by  irritability  and  incontinence.  1 
would  refer  my  readers  to  two  such  cases  candidly  published  by  Mr.  H.  Fenwick 
in  his  instructive  book,   Cardinal  Symptoms  of  Urijiary  Biseasef.'i^.  200. 

VOL.    II.  25 


386  OPERATIONS  ON  THE  ABDOMEN. 

ference  in  the  early  stage  of  tubercular  mischief — a  stage  in  which 
alone  can  such  treatment  be  expected  to  be  curative  — let  us  con- 
sider what  are  the  conditions  present  at  this  early  stage.  To  put 
it  briefly,  it  is  not  one  suitable  for  curetting,  &c.,  as  is  often  the  case 
Avith  tubercular  mischief  elsewhere.*  The  mucous  membrane  is  swollen, 
very  vascular,  velvety,  at  times  gelatinous.  Any  idcers  present  are 
often  small,  even  minute  and  numerous,  so  that  it  is  impossible  to 
make  sure  of  efficient  curetting,  especially  when  anyone  familiar  with 
the  interior  of  the  bladder  knows  how  quickly  a  little  bleeding  hides 
the  field  of  operation,  and  the  fact  that  the  mischief  is  usually  most 
marked  on  the  posterior  wall,  trigone,  and  neck.  The  following  is  a 
good  description  of  a  condition  often  jn-esent  in  these  cases  (J.  Bell, 
M.D.,  of  Montreal,  "Treatment  of  Tuberculosis  of  the  Bladder  b}^  a 
8upra-pubic  ^Section,"  Journ.  Cutan.  and  Genit.  Urin.  Bis.,  1892,  p.  298): 
"  The  trigone  and  a  band  of  about  an  inch  in  depth  around  the  urethral 
orifice  were  the  seat  of  many  superficial  ulcers,  varying  in  size  from 
that  of  a  split  pea  to  irregular  patches  as  large  as  a  five-cent  piece. 
The  mucous  membrane  of  the  whole  fundxis  of  the  bladder  was  also 
studded  with  small  tubercles  which  had  not  advanced  to  the  stage  of 
ulceration  nor,  indeed,  even  to  the  length  of  showing  signs  of  caseation. 
The  ulcerated  patches  were  scraped  and  cauterised,  but  the  little  non- 
ulcerated  tubercles  were  left  untouched.  They  were  so  numerous  that 
it  would  have  been  impossible  to  deal  with  each  one  singly."  Mr. 
Battle's  case  (Clin.  Soc.  Trans.,  vol.  xxiii.  p.  201),  which  was  greatly 
benefited  by  scraping  after  other  treatment  had  failed,  owes  its  success 
largely  to  the  condition  found,  which  \\'as,  I  think,  a  very  rare  one. 
The  ulcerated  surface  was  single,  though  very  extensive,  spreading  over 
the  left  lateral  and  posterior  wall,  from  the  trigone  almost  to  the 
summit,  with  the  bladder  relaxed.  After  the  ulcer  had  been  scraped, 
it  was  dabbed  over  with  a  solution  of  chloride  of  zinc  (30  gr.  to  §j). 
The  patient  was  seen  nearl}^  a  year  later,  soundly  healed  and  able  to 
hold  her  water  for  three  hours  at  a  time.  It  is  not  stated  whether 
pyrexia  was  then  present,  (ii)  For  these  reasons  I  am  strongly  of 
opinion  that  in  the  earlier  stages  we  should  treat  tubercular  disease 
of  the  bladder  not  by  operation  f  but  by  improving  the  hygienic  sur- 
roundings, especially,  whenever  it  is  possible,  getting  the  patient  to  be 
much  in  the  open  air,  if  possible  by  the  sea,  teaching  him  to  wash 
out  his  bladder  with  iodoform  emulsion  and  dilute  mercury  perchloride 
lotion,  and  in  the  case  of  a  woman,  giving  an  anaesthetic  at  intervals  and 
swabbing  over  the  mucous  membrane  with  a  solution  of  AgNOg  3ij — J,], 
the  urethra  having  been  rapidly  dilated,  (iii)  The  cases  that  call  for 
operative  interference  are  those  in  which  what  I  may  be  allowed  to  call 


*  Prof.  Guyon  reported  (.l»w.  dcs  Malad.  (Ux  ]'oies  Urin.,  Nov.  1889),  very  fully, 
four  cases  which  he  treated  by  curetting  and  the  cautery  after  a  supra-pubic  cysto- 
tomy. One  of  the  four  died,  two  years  after  the  operation,  the  patient  having  a 
persistent  sinus  and  being  bedridden  most  of  the  time.  One  died  within  the  year, 
and  one  within  about  three  months  of  the  operation.    The  fourth  had  survived  four  years. 

t  Dr.  L.  Bolton  Bangs,  of  New  York,  whose  experience  in  diseases  of  the  genito- 
urinai-y  organs  is  a  very  wide  one,  thus  expresses  himself  on  this  matter:  "After 
faithful  and  zealous  efforts  to  relieve  by  surgical  interference  the  local  symptoms 
of  these  cases,  I  have  Ijeen  forced  to  the  conclusion  that  the  less  instrumentation 
we  resort  to  the-  better." 


OPERATIVE  INTERFERENCE  IX  TUBERCULAR  DISEASE. 


387 


hygienic  treatment  has  failed,  oi'  in  which  the  case  has  got  beyond  this, 
where  pain  is  incessant,  micturition  freqiient — e.g.,  every  half-hour  day 
and  night,  with  much  tenesmus,  and  where  opiates  are  required  to 
afford  sleep.  There  should  be  no  advanced  disease  present  of  the  other 
urino-genital  organs,  kidneys,  lungs,  &c.  (iv)  The  supra-pubic  opera- 
tion is  always  to  be  preferred.  The  perinseal  gives  very  little  room, 
and  moreover  has  the  great  drawback  that  a  tube  thus  introduced 
will  very  likely  press  upon  the  neck,  or  trigone,  parts  very  liable 
to  be  attacked  b}'  tubercle.  Again,  this  opening  has  a  great  tendency 
to  close  before  the  full  benefit  of  drainage  has  been  secured.  The 
vaginal  opening  seems  to  me  to  be  liable  to  the  same  objection  as  the 
perinasal — viz.,  that  the  vesical  end  of  a  tube  thus  introduced  is  very 
likely  to  rest  against  an  ulcerated  surface,  (v)  The  patient  should  be 
warned  that  supra-pubic  drainage  often  involves  prolonged  confinement 
to  bed,  and  that  the  discomforts  which  must  attend  the  constant 
soakage  of  urine  are  only  to  be  partially  met  by  the  use  of  large 
Absorbent  pads,      (vi)  The  tube  should,   if  possible,   be  withdrawn   in 


Fig.  159. 


Trenclelenberg's  position.     (R.  Harrisou.) 

iibout  three  weeks,  and,  as  soon  as  the  wound  is  closed,  every  effort 
should  again  be  made  to  place  the  patient  under  the  best  hygienic 
surroundings,  to  the  necessity  of  which  I  have  alluded  above.  Hospital 
patients  should  be  got  into  better  air  at  once.  But  too  often  the  after- 
treatment  of  supra-pidDic  cystotomy  for  tubercular  cystitis  resolves  itself 
into  the  following  dilemma.  If  the  opening  is  closed  all  the  pain,  &c., 
soon  recurs  ;  if  it  is  kept  open  there  is  much  difficulty  in  preventing 
noisome  soaking.  A  tube  and  plug  worn  in  the  supra-pubic  sinus 
rarely  acts  well  in  these  cases,  where  the  bladder  is  often  small, 
contracted  and  thick-walled.  (vii)  The  patient  maj'-  enjoy  years  of 
fairly  active  and  happy  life  after  a  supra-pubic  c^'stotomy,  if  the 
opening  has  closed  within  a  reasonable  time  of  the  operation,  but  he 
will  be  liable  to  other  outbreaks  of  tubercular  mischief,  secondary  to 
disease  which  was  probabh'  present,  though  quiescent,  at  the  time  of 
the  cystotomy — e.g.,  tubercular  testis  and  kidney. 

Operation. — The  details  of  a  supra-pubic  cystotomy  are  so  frilly 
given  at  pp.  379,  400,  that  it  is  needless  to  repeat  them  here.  I  will 
£)nly  add  the  caution  that  great  care  must  be  taken  in  distending  these 


388  OPERATIONS  ON  THE  ABDOMEN. 

bladders.  Four  to  six  ounces  Avill  be  as  much  as  can  usually 
be  injected  with  safety.  The  bladder  is  first  opened  and  its  interior 
exposed  with  some  suitable  speculum  (p.  379).  aided,  if  needful,  l>y  the 
Trendelenberg  position  (P'ig.  159).  Any  ulcers  should  be  carefully 
and  thoroughly  curetted  or  cauterised  with  a  fine  point  of  the  Paquelin's 
thermo-cauter}',  iodoform  rubbed  over  the  surface  or  left  in,  in  the  shape 
of  the  emulsion.  To  any  very  vascular,  gelatinous-looking  mucous 
membrane,  not  ulcerated,  a  solution  of  AgNO^  3ij — §]*  should  be 
applied  on  a  small  sponge  on  a  holder. 

The  following  is  a  good  instance  of  the  relief  which  supra-pubic 
cystotomy  ma}'  give  in  a  ver}^  obscure  case  : — 

In  May  1890  I  was  asked  by  Dr.  Cock  and  Dr.  Hodgson,  of  Exniouth.  to  explore  the 
bladder  of  a  gentleman,  aged  57.  suffering  from  painful  cystitis,  lijematuria,  and 
frequent  micturition,  to  which  general  treatment,  washing  out  the  bladder  and 
drainage  by  a  catheter,  had  failed  to  give  any  relief.  Calculus  being  excluded  by 
sounding,  and  there  being  no  rectal  enlargement  of  the  prostate,  I  expected  to  find 
a  small  malignant  growth,  as  the  symptoms  were  too  urgent  for  prostate  trouble,  and 
as  this  gland  was  not  enlarged  either  to  the  finger  or  the  sound.  The  bladder,  having 
been  opened  and  emptied  by  the  supra-pubic  method,  at  first  appeared  normal  save  for 
some  sub-acutely  inflamed  rugte  which  stood  out  very  distinctly  on  the  right  lateral 
aspect  of  the  neck  of  the  bladder.  A  small  electric  lamp  at  once  showed  amongst  these 
folds  two  ulcers  each  about  i  inch  by  4:-inch,  oval  in  shape,  with  muscular  fibre 
clearly  exposed  on  their  floors,  their  edges  neither  thickened  nor  indurated.  They 
were  scraped  with  a  sharp  spoon,  and  iodoform  was  then  rubbed  into  their  surfaces. 
The  patient  made  an  excellent  recovery,  and  now,  six  years  later,  remains  quite  well. 
In  this  patient,  with  a  deep,  fat  perinneum,  I  should  never  have  detected  the  ulcers 
by  the  perinseal  route. 

PARTIAL    PROSTATECTOMY. 

We  owe  our  knowledge  of  what  this  operation  can  do  to  the  late  Mr. 
McGill,  of  Leeds  (Brit.  Med.  Joicrn.,  Oct.  19.  1889).!  The  following 
propositions  are  taken  from  his  paper : — i.  Prostate  enlargements 
which  give  rise  to  symptoms  are  intra-vesical,  not  rectal.  Thus- 
prostates  of  immense  size  which  project  towai"ds  the  rectum  cause  no 
virinar}'-  trouble,  while  severe  sjanptoms  may  supervene  when  the  pros- 
tate on  rectal  examination  is  apparently  of  normal  dimensions, 
ii.  There  are  many  varieties  of  the  intra-vesical  growth.  We  find 
(i)  a  projecting  middle  lobe — peduncidated  or  sessile,  (2)  a  middle 
lobe  with  lateral  lobes  forming  three  distinct  projections,  (3)  the  lateral 
lobes  alone,  (4)  a  pediinculated  growth  springing  from  a  lateral  lobe, 
and  (5)  "  a  uniform  circular  projection  surrounding  the  internal  orifice 
of  the  urethra."  This  variety,  described  by  Brodie,  is  not  infrequent, 
it  surrounds  the  urethra  like  a  collar,  and  projects  for  a  variable 
distance  into  the  bladder,     iii.    In  many  cases  self-catheterism  is  the 

*  This  may  appear  strong,  but  it  gives  very  marked  relief.  In  women  it  may  be 
applied  at  repeated  intervals  after  dilatation  of  the  iirethra.  If  it  should  give  much 
pain,  which,  in  my  experience,  it  rarely  does,  a  solution  of  sodium  chloride  may  be 
injected. 

f  Much  information  will  be  found  in  the  following  papers: — Watson,  Arm.  of  Surg., 
1889,  pp.  1-27;  Belfield,  ^ImcT.  Journ.  Med.  Scl.,  Nov.  1890;  MouUin,  Brit.  Mecl.Journ., 
1892,  vol.  i.  pp.  1185,  1250,  1294;  White,  Ann.  of  Sury..  1893,  p.  152  ;  AVoolsey,  Joitrn.^ 
Cut.  and  Gen.  Urin.  Dis.,  July  and  Aug.  1895. 


pai;tial  pkostatectomy.  389 

only  treatment  required,  iv.  That  when  this  fails,  or  is  unavailable, 
more  radical  measures  are  necessary,  v.  That  this  treatment,  to  be 
effectual,  should  (i)  for  a  time  thoroughly  drain  the  bladder;  (2)  per- 
manently remove  the  cause  of  the  obstruction.  vi.  That  the  supra- 
pubic route  is  preferable  to  the  perinfeal  for  prostatectomy.  Most 
surgeons  will  agree  with  this ;  the  question  is  alluded  to  at  p.  378,  and 
again  below.  This  operation  was  short-lived,  as  it  was  laid  aside  for 
the  much  less  severe  one  of  double  castration.  This  step  has  given  such 
encouraging  results  (p.  479)  that  it  will  probably  replace  prostatectomy 
in  many  of  those  cases  which  call  for  some  opei'ative  interference. 

Indications. — As  double  castration  seems  to  give  sufficient  relief  at  a 
very  much  smaller  risk,  it  appears  to  me  that  prostatectomy  should  be 
confined  to  the  following  cases  : — (i)  Where  one  or  more  calculi  co-exist 
with  an  enlarged  prostate.     I  have  myself  operated  on  two  such  cases. 

In  one,  the  patient,  aged  58,  was  in  a  condition  of  extreme  misery  from  cystitis, 
dysuria,  and  tenesmus,  and  the  catheter  had  to  be  resorted  to  every  ten  minutes.  By 
supra-pubic  cystotomy  I  removed  a  calculus  and  prostatic  tissue  from  the  median  and 
lateral  lobes  weighing  three-quarters  of  an  ounce.  He  made  a  good  but  slow  recovery, 
the  sinus  being  very  tardy  in  closing.  Two  years  after  he  was  holding  his  water  for 
three  or  four  hours  in  the  day,  and  was  only  disturbed  once  at  night.  The  residual 
urine  amounted  to  about  half  an  ounce.  In  the  other  patient,  a  calculus  and  great 
vesical  enlargement  of  the  prostate  co-existed  in  a  man  of  59,  whose  kidnej's  we  knew 
to  be  damaged.  After  removal  of  the  calculus  and  an  ounce  and  three-quarters  of 
enlarged  prostate  the  patient  did  well  for  two  days.  An  injection  of  morphia  had 
produced  such  grave  symptoms  that  I  forbade  any  more  being  given.  The  patient's 
restlessness  being  troublesome,  the  house-surgeon,  thinking  that  he  knew  best,  dis- 
obeyed my  directions  and  repeated  the  morphia.  Contracted  pupils  and  stupor  quickly 
followed  and  the  patient  sank.  At  the  necropsy  the  kidneys  were  granular ;  the 
remains  of  the  prostate  showed  the  usual  ragged  surface,  but,  under  the  circumstances, 
not  an  unhealthy  one. 

(2)  Where  the  operation  of  double  castration  fails,  as  it  does  in  some 
cases.  (3)  When  a  patient  refuses  double  castration  but  is  willing  to 
submit  to  the  greater  risk  which  has  been  fully  explained  to  liim.  The 
cases  I  consider  to  justify  operative  interference  are  given  under  the 
heading  ••  Castration"  (p.  479).  The  patient  will,  of  course,  be  got  into 
as  satisfactory  condition  as  possible  before  operation  by  attention  to 
aperients,  baths,  diet,  drugs,  such  as  urotropine  and  sandal-wood,  and 
washing  out  the  bladder. 

Choice  of  Operation. — The  surgeon  has  to  make  a  choice 
between  a  number  of  different  methods,  all  of  which  have  their  advocates. 
The  following  are  the  most  important  of  these : — 

1.  McGill's  supra-pubic  method  ic'dlioid  perinaeal  drainage. 

2.  Fuller's  supra-pubic  method  combined  with  perinteal  drainage. 

3.  \on  Dittel's  operation,  which  consists  of  removal  of  the  prostate 
by  means  of  an  extensive  dissection  of  the  perinteum. 

4.  Xichol's  operation  by  which  the  prostate  is  dissected  out  through 
the  perinajum,  pressure  being  made  from  above  through  a  supra-pubic 
cystotomy  wound. 

5.  Alexander's  operation,  which  is  Xichol's  operation,  with  the 
addition  that  the  bladder  is  drained  through  a  perinaeal  opening. 

It  Avill  be  seen  that  the  choice  lies  between  reaching  the  prostate 
through  a  supra-pubic  opening  into  the  bladder  or  by  means  of  a  deep 
dissection  of  the  perinajum.     The  supra-pubic  operation  has  the  great 


390  OPERATIONS  OX  THi:  ABDOMEX. 

advantage  that  hy  it  the  enlarged  prostate  can  be  best  seen,  felt, 
examined  and  oj)erated  upon.  It  is  much  more  generally  applicable,  as 
bv  it  both  the  middle  and  lateral  lobes  can  be  entirely  removed  if  neces- 
sary, as  shown  by  Freyer  (Brit.  Med.  Joiirn.,  vol.  ii.  1901,  p.  125),  who 
describes  four  successful  cases  of  removal  of  the  entire  prostate  by  the 
supra-pubic  route.  It  admits  of  our  doing  this,  aided  by  an  electric 
lamp  if  needful,  with  much  more  precision  and  completeness.  On  the 
other  hand,  the  perinagal  roiite  gives  mvich  the  best  drainage  and  is  best 
suited  for  the  removal  of  sub-urethral  growths,  and  for  some  cases  of 
enlargement  of  the  lateral  lobes,  e.'j.,  where  this  is  not  only  intra-  but 
extra-vesical,  and  so  closing  the  prostatic  urethra.  These  cases  are, 
however,  rare ;  as  a  rule  we  have  to  deal  with  hypertrophy  of  the  median 
lobe  and  of  the  intra-vesical  aspects  of  the  lateral  lobes,  and  all  the  work 
that  is  required  can  be  done  from  the  interior  of  the  bladder.  The 
perin^eal  route  has  the  serious  drawbacks  of  giving  very  little  room  ; 
by  it  operating  is  done  in  the  dark ;  in  patients  with  a  deep,  fat 
perineeum  the  "  perinaeal  distance "'  may  make  it  quite  impossible  for  the 
operator  to  satisfactorily  remove  the  obstruction.  Moreover,  the 
perinfeal  dissection  must  needs  be  extensive  and  difficult,  and  presumably 
altogether  a  more  severe  operation  than  a  supra-pubic  wound. 

The  mortality  of  the  operation  is  high,  varying  between  15  and  20 
per  cent,  in  the  different  collections  of  cases,  but  is  somewhat  higher 
after  the  perinaeal  methods  than  the  supra-pubic  ones. 

For  these  reasons  the  supra-pubic  operation  is  certainly  to  be  pre- 
ferred to  the  perineal,  which  should  onh'  be  undertaken  in  those  rare 
cases  in  which  it  is  found  impossible  to  remove  the  obstruction  through 
the  supra-pubic  wound  alone. 

As  a  rule,  then,  the  surgeon  should  begin  with  the  supra-pubic 
method,  adoj^ting  the  perinaeal  afterwards,  if  he  finds  it  necessary,  in 
order  to  secure  a  low-level  route  for  the  removal  of  extra-vesical  lateral 
or  sub-urethral  enlargements,  or  to  secure  efficient  drainage. 

Operation. — The  full  accounts  of  supra-pubic  cystotomy  given  at 
pp.  379  and  399  should  be  referred  to ;  onl}-  those  points  which  relate  to 
the  special  technique  of  prostatectomy  will  now  be  given.  The  quantity 
of  water  (p.  40 1 )  injected  into  the  rectal  bag.  if  one  is  used,  especially 
when  the  prostate  is  abnormally  hard,  should  not  exceed  six  to  eight 
ounces.  Where  the  bladder  is  contracted  with  thick  non-distensible 
walls,  it  will  iisually  be  inadvisable  to  perform  this  operation.  A 
catheter  left  in  the  bladder,  till  this  is  opened,  expedites  the  operation. 
Mr.  McGill  advised  that  the  bladder  be  stitched  to  the  cut  edges  of 
the  wound  before  any  attempt  be  made  to  remove  the  prostate.  If 
this  is  done  it  will  interfere  with  the  subsequent  suture  of  the  bladder 
^^•hich  I  recommend  below.  I  think  the  same  end  can  be  secured  by 
holding  the  bladder  well  up  with  a  pair  of  Spencer  Wells's  forceps  on 
either  side,  each  taking  hold  at  a  point  opposite  to  the  part  to  be  left 
open  when  the  sutures  are  inserted  (vide  infra).  Enucleation  is  to  be 
performed  as  much  as  possible  by  the  finger.  This  not  only  prevents 
haemorrhage,  bvit  the  finger  will  turn  oiit,  far  more  intelligently,  safely, 
and  quickly,  much  larger  pieces  than  any  vulsellum  or  punching- 
forceps.  First,  however,  a  way  must  be  made  for  the  finger.  This  is 
effected  b}"  taking  away  any  projecting  portions  with  such  forceps  as 
Jessop's,  or  by  dividing  the  overlying  mucous  membrane  with  scissors 


LATERAL  LITHOTOMY.  39 1 

as  described  bj'  Dr.  E.  Fuller,  of  New  York  (Journ.  Cat.  and  Gen.  JJrin. 
Dis.,  June  1895,  p.  232).  The  bladder  having  been  opened,  the  extent 
of  the  prostatic  enlargement  and  the  site  of  the  m-ethral  opening  are 
determined  :  ''A  pair  of  rough,  serrated-edged  scissors  with  a  long 
handle  grasped  in  the  right  hand  are  slipped  along  the  left  forefinger 
into  the  urethral  opening,  and  are  made  to  cut  through  the  bladder  wall 
in  that  region.  The  cut  extends  from  the  lower  margin  of  the  internal 
vesical  opening  of  the  urethra  backward  for  an  inch  or  an  inch  and  a 
half.-  The  blades  of  the  scissors  being  rough  and  serrated,  make  an 
incision  w^hich  bleeds  but  little.  Then  one  of  the  forefingers,  whichever 
the  operator  ma}'  find  the  more  convenient,  is  slipped  through  the 
vesical  hole  made  by  the  serrated  scissors,  while  at  the  same  time  the 
fist  of  the  other  hand  makes  firm  counter-pressure  against  the  perinaeum. 
By  means  of  this  counter-pressure  the  prostatic  growth  is  brought  well 
within  reach  of  the  forefinger  of  the  other  hand,  which  is  employed  all 
the  time  in  enucleating  the  obstruction  en  ma^^se.  or  piece  by  piece,  as 
the  case  may  be.  This  enucleation  should  not  be  desisted  in  until  all  the 
lateral  and  median  hypertrophies,  as  well  as  all  hypertrophies  along 
the  line  of  the  prostatic  urethra,  have  been  removed."  Dr.  Fuller  states 
that  owing  to  the  small  amount  of  bleeding  he  has  always  found  it 
feasil^le  to  sew  up  the  supra-pubic  incision  as  described  below,  and  that 
lie  has  never  had  trouble  with  secondary  hsemorrhage.  A  perin^eal 
section  is  next  made  and  a  large-sized  rubber  tube  passed  through  the 
perinaeal  incision,  and  that  through  which  the  prostate  was  enucleated, 
into  the  bladder.  After  this  hot-water  irrigation  is  emplo\^ed  for  some 
time  to  stop  oozing.  Next,  the  supra-pubic  wound  is  closed  by  a  deep 
layer  of  catgut  sutures  which  include  the  bladder  wall,  and  by  a  more 
superficial  layer  of  silk-worm  gut.  The  middle  of  the  incision  is  not 
closed,  but  a  deep  provisional  salmon-gut  suture  is  inserted  here,  taking  up 
the  walls  of  the  bladder  and  the  abdomen.  A  drainage-tube  is  inserted, 
and  when  this  is  removed  in  four  or  five  days  the  provisional  suture  is 
tightened  up.  Six  cases  of  prostatectomy,  five  of  these  operated  on  by 
this  supra-pubic  method,  are  given  by  Dr.  Fuller ;  all  were  successful. 

After  the  surgeon  has  removed  all  that  he  considers  necessary  from 
within  the  bladder  he  must  carefully  examine  the  urethra  both  with  his 
finger  and  by  full-sized  catheters  passed  from  the  meatus.  Belfield 
attaches  great  importance  to  this.  In  one  of  his  cases,  after  removing 
from  the  left  lateral  lobe  as  much  as  a  walnut,  he  found  that  there  was 
still  an  obstruction  in  the  prostatic  urethra  to  the  passage  of  a  catheter. 
By  perintfial  section  a  rounded  mass  was  shelled  out. 

Hgemorrhage  must  be  arrested  by  the  means  given  at  p.   382. 

The  amount  removed  must  vary  with  each  case.  Prostatic  tissue  is 
not  heavy,  and  any  amount  over  an  ounce  and  half  will  be  rarely 
removed.  Mr.  Buckston  Browne  {Clin.  Soc.  I'rans.,  vol.  xxii.  p.  274) 
removed  in  one  case  gland  tissue  amounting  to  nearly  four  ounces.  A 
good  recoverv  followed. 

LATERAL  LITHOTOMY  (Figs.    1 60.    l6r.    162). 

Owing  to  the  introduction  and  perfection  of  the  cnishing  operation 
for  stone,  lateral  lithotomy  is  now  seldom  called  for.  The  chief  in- 
dications are  : — (i)  In  children,  when  the  stone  ig  a  small  one.  and 


392  UPEPtATIOXS  OX  THE  ABDOMEN. 

when  the  surgeon  is  inexperienced  in  the  nse  of  the  lithotrite,  it  is 
the  operation  of  choice.  (Vide  also  the  remarks  on  pp.  421-423.) 
(2)  In  the  case  of  a  large  stone  with  which  it  has  been  decided  to  deal 
hj  perinasal  lithotrity  (p.  421)  the  bladder  is  opened  by  the  same  steps 
as  in  lateral  lithotomy.  (3)  In  certain  cases  of  stricture  of  the  urethra 
and  enlarged  prostate,  where  a  staff  can  be  passed.  In  the  majority 
of  the  cases  of  enlarged  prostate,  however,  the  supra-pubic  method  is 
to  be  preferred,  as  by  this  means  the  prostatic  hypertrophy  can  be 
more  readily  dealt  with  at  the  same  time   (p.  399). 

The  lateral  operation  will  be  described  under  the  following  heads : 

A.  Preparatory  Treatment. 

B.  Passing  the  Staff.    Possible  DifB.culties. 

C.  Finding  the  Stone.    Possible  Difllculties. 

D.  Entering  the  Bladder.    Possible  Diflaculties. 

E.  Extracting  the  Stone.    Possible  Difliculties. 

A.  Preparatory  Treatment. — For  a  week  or  so  before  the 
operation  the  diet  should  be  bland,  so  as  to  tax  as  little  as  possible 
jaded  kidneys — e.g.,  milk,  barley-Avater,  light  puddings,  and  a  little 
fish.  If  alcohol  is  needed,  some  sound  spirit,  w^ell  diluted,  should  be 
given.  Baths  should  be  taken  regnilarly,  the  bowels  well  moved,  and 
an  enema  given  on  the  morning  of  the  operation,  and  care  should  be 
taken  that  all  this  has  come  away. 

B.  Passing  the  Staff. — This  step,  however  simple  and  easy 
usuall}',  presents  occasional  difficulties,  the  more  trying,  because  perhaps 
unlocked  for ;  they  are — 

(l)  Sj)asm,  from  the  urethra  not  being  used  to  instruments.  (2) 
Stricture.  (3)  A  false  passage.  (4)  An  enlarged  prostate.  (5)  An 
enlarged  prostatic  sinus,  into  which  the  end  of  the  sound  passes.  Mr. 
Buckston  Browne's  staff  meets  the  last  two  admirably. 

C.  Finding  the  Stone  with  Sound  or  Staff.  Possible 
Difficulties. 

(i)  The  stone  may  have  been  passed.*  This  is  not  impossible  in 
children  with  small,  smooth,  narrow  calculi,  and  their  sudden,  strenuous 
micturition.  (2)  The  stone  may  lie  behind  an  enlarged  prostate. 
Here  the  finger  of  an  assistant  passed  into  the  rectum  may  help.  (3) 
The  stone  may  be  enveloped  in  folds  of  mucous  membrane.  Injection 
of  the  bladder  is  here  indicated.  (4)  The  stone  may  be  encysted.  This 
is  so  rare  as  to  have  been  called  '•the  refuge  of  young  lithotomists." 
The  following  case  of  Sir  G.  Humphry  [Some  Cases  of  Operation. 
pamphlet.  1 856)  shows  well  how  embarrassing  this  condition  may  be  : 

A  man,  aged  51,  was  cut,  then  submitted  twice  to  lithotrity,  then  again  cut  in  the 
old  scar  three  times,  all  within  six  years,  for  an  encysted  calculus.  On  the  fourth 
occasion  of  lateral  lithotomy  the  nature  of  the  case  was  made  out  accurately.  The 
stone  was  now  felt  behind  the  prostate  attached  to  the  bladder  by  a  pedicle  which 
seemed  to  penetrate  the  coats  of  the  viscus.  and  to  be  attached  to  another  mass  beyond 
it.  It  was  evidently  a  stone  of  hour-glass  shape,  part  being  in  the  bladder  and  part 
in  the  sac.  At  each  of  the  previous  operations  the  part  within  the  bladder  had 
broken  off,  the  rest  not  being  extracted,  owing  to  the  size  of  the  prostate.  The 
symptoms  recurring,  urethro-rectal  lithotomj'  was  performed.  The  stone  being  now 
within  reach,  the  edge  of  the  mucous  membrane  around  it  was  incised  with  a  hernia 


*  Cf.  the  case  mentioned  by  Mr.  Holmes.  Clin.  Sor.  I'rans.,  vol.  ii.  p.  67. 


LATERAL  LITHOTOMY. 


393 


knife,  and  a  stone,  the  size  of  a  walnut,  and  with  a  truncated  stalk,  extracted.  Death 
took  place  in  two  days,  from  pelvic  cellulitis.  Though  the  bladder  was  otherwise  but 
little  diseased,  the  cyst  seemed  to  have  originated  from  the  protrusion  of  mucous 
membrane  between  the  muscular  fibres,  as  another  one  existed,  though  without  a 
stone.  The  cyst  communicated  by  a  considerable  opening  with  the  foul,  infiltrated 
tissues.     Sir  George  points  out  that  these  cysts  may  be  quite  out  of  reach  in  lateral 

Fig.  i6o. 


(Fergussou.) 

lithotomy.  As  their  walls  consist  only  of  cellular  tissue,  mucous  membrane,  and 
perhaps  a  thin  layer  of  muscular  fibre,  they  are  easily  lacerated  during  an  operation, 
an  accident  almost  certain  to  be  fatal.  The  diagnosis  is  usually  to  be  made  if  the 
stone  is  always  struck  by  the  sound  at  one  spot,  especially  if,  per  rectum,  a  lump  is 

Fig.  i6i. 


(Fergusson.) 


detected  corresponding  to  that  spot, 
see  footnote,  p.  jqq. 


The  supra-pubic  operation  is  indicated  here, 


*  Sir  J.  E.  Erichsen  (^Surgery,  vol.  ii.  p.  945)  adds  that  the  beak  cannot  be  made  to 
pass  round  such  a  stone,  so  as  to  isolate  it.  To  several  other  allied  conditions  of 
complicated  stone,  see  the  reference  at  p.  411. 


394 


OPERATIONS  ON  THE  ABDOMEN. 


D.  Entering  the  Bladder. — The  time  chosen  for  introdvicing  the 
staff  varies  with  different  operators.  Passing  the  staff  while  the  patient 
is  still  recumbent  is  the  easier ;  passing  it  when  the  patient  is  in  litho- 
tomy position  is  rather  more  difficult,  but  secures  the  operator  against 
the  risk  of  the  staff  slipping  out  after  the  patient  is  brought  down  into 
position,  a  risk  which  is  greater  wdth  the  straight  staff.  I  prefer  to 
bring  the  patient's  lower  limbs  over  the  edge  of  the  table,  to  pass  the 
sti'aight  staff  while  he  is  recumbent,  and  then  to  have  his  limbs  only 
brought  up  into  position. 

The  nates  just  projecting  over  the  edge  of  the  table,  the  sacrum  being 
flat  upon  it,  the  flexed  thighs  and  legs  being  held  well  out  of  the  way, 
the  surgeon,  seated  comfortably,  and  with  his  face  on  a  level  with  the 
perinaeum,  directs  an  assistant  so  to  hold  the  staff  as  to  bring  the  mem- 
iDranous  urethra  close  to  the  surface  of  the  perina)um.  If  a  curved  staff 
be  used,  this  is  easily  done  by  inclining  the  handle  strongly  towards 
the  abdomen.  By  this  manoeuvre,  in  Mr.  Cadge's  words  (Joe.  supra 
cit.),  the  point  of  the  staff  "need  not,  and  should  not,  be  withdrawn 
from  the  bladder,  but  if  it  were  it  would  be  of  no  moment,  because  it 


Fig.  162 


Lateral  lithotomy  with  a  straight  staff.     (Key.j 

would  re-enter  it  the  moment  the  handle  is  raised  ;  the  membranous 
urethra,  instead  of  being  almost  perpendicular  to  the  surface  of  the 
peringeum,  as  it  is  when  the  staff"  is  held  upright,  is  brought  almost 
parallel  with  it,  and  is  much  easier  to  find  with  the  knife ;  there  is  no 
inducement  to  open  the  urethra  too  far  forwards,  and  consequently  no 
risk  of  wounding  the  bulb  or  its  artery.  The  staff  gets  a  steady  rest 
against  the  front  of  the  pubes,  and  there  is  no  danger  to  the  rectum  at 
this  stage."  It  thus  combines  the  advantages  of  the  two  very  different 
methods  usually  given — viz.,  either  to  hold  the  staff  well  up  firmly 
under  the  pubes  and  thus  away  from  the  bowel,  but  also  awa}'  from 
the  stone  ;  or  closely  down  upon  the  latter  and  in  proximity  to  the 
rectum  also. 

Having  felt  the  staff  thus  presented  towards  him,  having  examined 
into  the  depth  of  the  ischio-rectal  fossa,  the  site  of  the  tuber  and  ramus 
ischii,  the  surgeon  pressing  up  the  junction  of  the  scrotum  and  raphe 
so  as  to  make  tense  the  parts  just  about  to  be  cut,  enters  his  knife  from 
a  quarter  of  an  inch  to  one  inch  and  a  half  from  the  anus,  just  to  the 
left  of  the  raphe,  and  very  likely  hits  the  groove  at  once.     The  knife  is 


LATERAL  LITHOTOMY.  395 

then  drawn  outwards  and  backwards  with  a  rapid  sawing  movement,  to 
a  point  midway  between  the  anus  and  tuber  iscliii.  thus  making  an 
incision  of  two  or  three  inches,  according  to  the  age  of  tlie  patient  and 
size  of  the  stone.  Again  inserting  the  knife  into  the  upper  angle  of 
the  wound,  the  surgeon  makes  out  exactly  with  his  left  index  finger  the 
groove  in  the  staff,  and  exposes  this,  beyond  doubt,  in  the  wound.  The 
next  steps  differ  somewhat,  accordingl}-  as  the  curved  or  straight  staff  is 
used — they  will  be  given  separately. 

{a)  With  the  Ciirved  Staft. — "When  the  knife's  point  is  felt  firmly 
lodged  in  the  groove,  its  handle  is  a  little  depressed,  the  blade,  at  the 
same  time,  turned  a  little  to  the  left,  is  pushed  steadily  along  the 
groove  till  a  gush  of  urine  or  a  sense  of  resistance  ceasing,  or  both 
together  usually,  announce  that  the  neck  of  the  bladder  has  been 
sufficiently  divided  with  the  knife.  The  finger  is  now  wormed  into 
the  bladder  over  the  concavity  of  the  staff. 

{h)  With  the  Straight  Staff. — When  the  point  of  the  knife  is  felt  to 
be  safeh^  lodged  in  the  groove,  the  surgeon  takes  the  handle  of  the 
straight  staff  from  his  assistant,  brings  it  down,  and  still  keeping  his 
knife  in  the  groove,  lateralises  the  staff  slightly  to  the  left,  the  handle 
of  the  knife  being  now  depressed  so  as  to  form  a  sufficient  angle  with 
it,  and  make  an  adequate  wound,  the  surgeon  runs  it  along  the  groove 
steadily,  till  he  knows  hy  the  above  given  evidence  that  the  neck  of  the 
bladder  has  been  sufficiently  cut. 

The  left  index  finger  is  next  wormed  over  the  edge  of  the  staff,  the 
straight  staff  being  held  by  the  surgeon  himself,  in  his  right  hand,  the 
curved  one  being  held  by  an  assistant,  till  he  feels  that  he  has  entered 
the  bladder  and  placed  the  finger  tip,  if  possible,  in  contact  with  the 
stone.  Entrance  into  the  bladder  is  known  by  feeling  the  finger  sur- 
rounded with  a  smooth  cavity,  lined  with  mucous  membrane,  while 
the  finger  itself  is  girt  b}'  a  fibrous  ring.  The  stone  being  felt,  or  the 
bladder  ca^^ity  distinctly  gained,  the  staff  is  withdrawn,  and  the  surgeon, 
while  taking  his  lithotomy  forceps,  dilates  the  opening  into  the  bladder 
with  his  finger,  which,  at  the  same  time,  pulls  down  and  steadies  the  neck. 

Failure  to  Enter  the  Bladder. — This  most  vexatious  and  embarrassing 
difficulty  is  most  likely  to  bt-  met  with  under  two  widely  different 
conditions — (i)  most  frequently,  in  little  children;  (2)  in  old  patients 
with  a  ver}^  fat,  deep  perineum,  and  enlarged  prostate.  The  first  must 
be  considered  separately. 

(i)  In  Little  Cliildren. — The  causes  here  are,  the  small  size,  delicacy, 
and  moljility  of  the  neck  of  the  bladder  and  urethra,  and  the  fact  that 
the  bladder  lies  high  up  above  the  pelvis.  Mr.  Cadge  quotes  the 
following  from  Sir  W.  Fergusson  : 

"  The  point  of  the  tiiiger  was.  as  usual,  placed  on  the  staff  and  pushed  gently 
towards  the  bladder.  The  finger  went  on,  but  I  was  aware  that  it  had  not  got  between 
the  urethra  and  the  staff.  With  an  insinuating  movement  (much  to  be  appreciated 
by  the  lithotomist,  who,  as  I  do,  professedly  makes  a  small  incision  in  this  locality), 
I  endeavoured  to  get  its  point,  as  usual,  into  the  urethra  and  neck  of  the  bladder. 
But  here  I  felt  convinced  that  I  had  failed,  and  was  aware  that  the  finger  was  getting 
deeper  as  regards  the  depth  of  the  perin«;um,  but  that  I  was  not  materially  nearer  the 
bladder.  I  could  feel  a  considerable  space  at  the  point  of  the  finger,  and  was  con- 
vinced that  the  upper  part  of  the  membranous  urethra,  as  well  as  the  sides,  had  given 
way  to  the  pressure,  and  that  now.  as  the  finger  was  getting  deeper  into  the  wound. 


396  operation;  S  ox  THE  ABDOMEN. 

I  was  only  pushing  the  prostate  and  ueck  of  the  bladder  inwards  and  upwards.  These 
parts  seemed  to  recede  before  the  smallest  imaginable  force,  whilst  I  felt  that  I  could, 
in  a  manner,  make  any  amount  of  space  around  the  bare  part  of  the  staff.  I  had  no 
diiEculty  in  distinguishing  between  the  surface  of  this  space  and  that  of  the  mucous 
membrane  of  the  bladder.  Moreover,  I  knew  that  I  had  never  crossed  that  narrow 
neck  which  is  always  felt  as  the  finger  passes  into  the  bladder  when  a  limited  incision 
is  maile.  An  impression  came  over  me  that  I  was  about  to  fail  in  getting  into  the 
bladder,  and  I  had  an  idea  that,  unless  I  could  open  the  urethra  in  front  of  the 
prostate  more  freely,  I  should  probably  never  reach  the  stone.  This  I  effected  with 
great  caution,  and  then  I  could  appreciate  the  passage  of  the  finger  as  usual  through 
the  neck  of  the  bladder.  The  stone  was  easily  touched  and  removed,  but  I  wa,s  forcibly 
impressed  with  the  idea  that  I  had  nearly  failed  in  the  performance  of  the  operation." 
The  child  here  was  4  years  old. 

Mr.  Cadge  thus  met  the  same  difficulty  in  an  infant  of  one  year  and 
a  half: 

"  I  felt  the  impossibility,  even  with  a  fair  incision,  of  distending  the  wound  with 
my  finger ;  it  was  like  trying  to  get  into  the  orifice  of  the  urethra.  I  therefore 
desisted  before  doing  any  harm,  and,  taking  a  pair  of  common  dressing-forceps, 
I  passed  them  easily  along  the  staff  into  the  bladder :  by  opening  the  blades  gently 
but  firmly,  room  was  gained,  and  the  finger  entered  and  made  room  for  small 
lithotomy-forceps.  But  I  have  repeatedly,  after  passing  the  dressing-forceps,  with- 
drawn the  staff  and  removed  the  stone  with  them,  and  without  introducing  the 
finger  at  all." 

Difficulties  and  Mistakes  during  this  Stage  of  entering  the 
Bladder. — This  is  so  important  a  part  of  the  operation  that  the  follow- 
ing may  be  enumerated  here  : 

I.  Finding-  the  staif.  This  is  not  likely  to  jDresent  difficulties  in  the 
case  of  a  curved  staff  if  it  be  held  as  advised  at  p.  393.  Hitting  a 
straight  staff  in  a  fat  child  is  not  always  eas}",  owing  to  the  small  size 
which  is  needful.  Attention  must  be  paid  to  entering  the  knife  at  the 
root  of  the  scrotum  only  jttst  to  the  left  of  the  raphe,  when  the  finger- 
nail Avill  detect  the  staff  at  once.  2.  Not  exposing  the  staff.  Ever}^- 
thing  which  lies  over  the  staff  in  the  upper  angle  of  the  wound  must  be 
clean  cut.  The  tissues  here,  including  the  membranous  urethra,  are  lax 
and  delicate,  and,  unless  the  knife  is  clearly  in  contact  with  metal,  the 
groove  will  not  be  followed.  3.  Losing  the  groove.  This  most  serious 
accident  may  be  due  to  not  getting  the  knife  cleanl}^  into  the  groove, 
not  keeping  it  sufficiently  firmly  in  contact  with  it,  and,  thirdly,  by 
forgetting  to  depress  slightly  the  handle  of  the  knife.  4.  Cutting  the 
prostate  too  freely  as  the  knife  is  Ijrought  out.  This  can  easily  be 
avoided  by  keeping  the  knife  sufficiently  near  to  the  staff.  5.  Cutting 
into  the  rectum.  This  may  be  due  to  neglect  of  the  following  pre- 
cautions :  (i)  Keeping  the  staff  up  away  from  the  bowel ;  (2)  guarding 
the  bowel  with  the  left  forefinger  in  the  Mound ;  (3)  when  the  knife  is 
lateralised,  cutting  away  from  the  gut.  Mr.  Cadge  (loc.  supra  cit.) 
points  out  that  the  usual  place  of  i)uncture  is  the  dilated  part  just 
above  the  internal  sphincter,  and  that  this  communication  may  be  made 
secondaril}^  b}-  sloughing  after  extraction  of  a  large  stone,  or  after  the 
use  of  a  plug  for  arresting  heemorrhage.  His  experience,  is  that 
"  Nature  seldom  fails  to  Ijring  about  a  cure,  or  so  to  contract  the 
wound  as  to  leave  but  trifling  inconvenience."  6.  Wounding  the 
posterior  wall  of  bladder. 

Sir  S.  Wells,  at  the  discussion  of  Sir  H.  Thompson's  paper  (Med.- 


LATERAL   LITHOTOMY.  397 

Chir.  Soc,  April  2,  1878).  mentioned  a  case  in  which  ]Mr.  Tyrrell 
wounded  the  back  of  the  bladder,  and  hence  always  advocated  a  short 
knife.  That  this  accident  happened  even  in  the  hands  of  Aston  Key 
himself,  I  know  through  the  father  of  an  old  Guy's  man  who  was 
present  at  the  time. 

E.  Finding  and  Extracting  the  Stone. — The  surgeons  left 

index  finger,  liaving  passed  into  the  bladdei'  along  the  concavity  of  the 
staff,*  finds  the  stone,  hooks  this  down  as  near  to  the  neck  as  possible, 
and  at  the  same  time  steadies  the  neck  while  it  dilates  the  incision  in 
it  and  in  the  prostate.  This  combination  of  movements  requires  most 
careful  attention  to  each  of  its  details  separately.  The  most  important 
of  these  is  the  dilatation  of  the  neck  and  prostate.  If  the  stone  is 
found  to  be  a  large  one.  the  deep  part  of  the  wound  must  be  sufficiently 
free.  It  is  well  known  how  much  has  been  written  on  thig  matter. 
The  surgeon  should  begin  by  dilating  the  neck  of  the  bladder  carefully 
and  equally  in  every  direction,  using  a  considerable  amount  of  force 
in  an  adult,  but  not  throwing  this  on  any  limited  portion  of  the  wound. 
It  may  be  accepted  as  a  certain  fact  that  the  wound  in  the  prostate  may 
extend  through  the  whole  of  this  body,  without  risk  of  cellulitis,  if  only 
the  recto-vesical  capsule  is  not  torn  through.  As  long  as  the  finger  is 
girt  by  a  fibrous  ring  this  mischief  has  not  been  done.  Whether  an 
extensive  wound  in  the  prostate  had  lietter  be  made  by  dilatation  and 
laceration  or  by  free  incision  will  probably  never  be  settled.  The  wise 
surgeon  will  avail  himself  of  a  safe  use  of  both — that  is  to  saj^,  after 
dilating  with  forcil^l^  but  equal  pressure  all  around  the  original  wound 
in  the  neck,  he  will  introduce  a  bkint-pointed  narrow-bladed  bistoury 
flat  against  the  pulp  of  his  finger,  and  nick  the  remaining  constriction 
at  one  or  two  places,  then  dilating  again. 

Xext  to  the  size  of  the  stone  the  age  of  the  patient  must,  here,  be 
considered.  After  middle  life,  the  cellular  tissue  around  the  neck  of 
the  bladder  is  not  only  loose,  but  abounds  in  enlarged  veins.  Hence 
the  risk  of  causing  not  only  cellulitis,  but  septic  phlebitis,  by  dilating- 
an  inadequate  opening  by  the  tearing,  bruising  exit  of  the  stone, 
instead  of  by  the  finger  and  knife  combined. 

The  deep  opening  having  been  thus  made  sufficiently  free,  the 
surgeon,  having  selected  his  forceps,  introduces  them  along  the  finger 
(thus  further  dilating  the  wound),  the  latter  being  withdrawn  as  the 
forceps  enter.  These  held  at  first  in  one  hand  (the  thumb  in  the  ring) 
are  fully  introduced  closed,  then  opened  widely  transversely,  and,  by  a 
quarter-turn  of  the  handles,  the  lower  blade  is  made  to  scoop  or  sweep 
along  the  floor  of  the  bladder,  which  will  almost  surely  catch  the  stone. 
If  this  step  fail,  it  is  repeated,  and  if  the  stone  is  still  not  caught,  the 
surgeon  feels  again  for  the  stone  either  with  the  closed  forceps  or  by 
again  inserting  his  finger,  which  will  bring  down  the  stone,  push  off 
projecting  folds  of  mucous  membrane,  &c.  Differently  curved  forceps, 
supra-pubic  pressure,  and  a  finger  in  the  rectum,  may  all  help  now. 

The  stone  being  caught,  the  finger  again  feels  if  it  is  held  in  its 
shorter  axis ;  if  so,  it  may  at  once  be  extracted,  if  moderate  in  size,  by 
steady  deliberate  traction  downwards  and  outwards.  As  long  as  the 
stone  advances  all  is  well ;  if  not,  gentle  rotation  may  again  start  it  on 


This  is  only  withdrawn  when  the  stone  is  felt,  not  before. 


398  OPERATIONS  ON  THE  ABDOMEN. 

its  way.  In  less  easy  cases  Mr.  Cadge's  words  should  be  remembered : 
"  Should  there  be  much  resistance  and  no  sense  of  gradual  yielding,  the 
surgeon  will  ask  himself  whether  this  is  due  to  an  insufficient  opening, 
or  to  the  projection  of  the  ends  of  an  oval  stone  laterally  beyond  the 
bladder.  This  latter  may  be  known  by  observing  that  the  bladder  is 
brought  bodily  down,  so  that  the  prostate,  which  is  probably  large,  is 
visible  near  the  external  wound ;  in  this  case  the  stone  must  be 
liberated,  the  finger  again  introduced,  and  a  fresh  hold  taken.  If  the 
obstruction  is  due  to  a  large  stone  and  too  small  a  wound,  the  latter  is 
to  be  enlarged  in  the  direction  of  the  first  incision  ;  this,  in  the  opinion 
of  the  Avriter,  is  i)refe)'able  to  making  the  division  of  the  neck  of  the 
bladder  on  the  opposite  side,  and  preferable,  too,  to  using  undue 
traction  and  force." 

In  son;e  cases  a  scoop  will  facilitate  extraction,  the  stone  being  firmly 
held  between  the  pulp  of  the  left  index  finger  and  the  concavity  of  the 
scoop.  In  childi'en  one  finger  in  the  rectum  and  one  in  the  bladder  will 
often  serve  the  purpose. 

The  stone  being  out.  the  bladder  is  carefull)-  explored  with  the 
finger,  or  a  short-beaked  staff,  aided  by  pressure  above  the  pubes,  or 
from  within  the  bowel,  for  any  other  calculi  or  fragments.  Multiple 
calculi  will  have  been  indicated  by  facets  upon  the  first. 

Anjr  bleeding  vessels  are  now  secured,  a  tube  introduced,  dressings 
applied,  and  the  patient  removed  to  bed. 

DiflS.culties  during  the  Stage  of  Extraction  of  the  Stone. 

( I )  The  position  of  the  stone.  This  may  be  out  of  reach  owing  to  its 
being  at  the  posterior  part  of  a  dilated  bladder,  above  the  pubes,  or  to 
the  patient  having  a  very  fat  and  deep  perina?um.  Pressure  above  the 
pubes,  and  the  use  of  long  forceps,  are  here  indicated.  (2)  An  enlarged 
prostate.  This  interfei'es  with  reaching  the  stone  both  with  fingers  and 
forceps.  Curved  forceps  passed  in  along  the  staff",  or  a  gorget,  if  the 
perineeum  be  very  deep,  will  be  helpful  here,  and  perhaps  a  bag  in  the 
rectum  would  aid  in  raising  up  the  stone  within  reach  in  difficult  cases. 
An  enlarged  middle  lobe  of  the  prostate,  or  a  separate  adenoma  of  this 
gland,  may  also  cause  trouble  by  getting  between  the  blades  of  the 
forceps.  Tearing  away  of  these  portions  of  the  gland  has  often 
occurred,  and  is  sometimes  certainly  beneficial.  It  is  doubtful,  however, 
if  this  is  always  so.  Thus  Mr.  Cadge  (loc.  suj/ra  cit.)  thinks  "that  it  is 
probable  that  a  careful  examination  of  the  subsequent  condition  of  such 
patients  would  show  that,  although  it  may  not  have  endangered  life,  it 
has  not  infrequently  been  followed  by  partial  inability  to  retain  urine." 
Prof.  Gross  (Trans.  Philad.  Path.  Soc,  vol.  iv.  p.  153)  thought  that  in 
one  case  the  cavity  left  behind  became  a  suppurating  pouch,  and 
increased  the  difficulty  in  micturition.  (3)  Breaking  up  of  the  stone. 
This  may  occur  with  hard  calculi  from  too  much  force  being  used  with 
the  forceps,  but  it  much  more  often  happens  with  soft  phosphatic 
calculi.  In  such  cases  every  fragment  must  be  cleared  out— a  matter 
of  some  difficulty,  as  small  ones  are  readily  concealed  in  clots  or  folds  of 
mucous  membrane.  After  all  the  larger  ones  are  picked  out,  a  catheter 
of  appropriate  size,  attached  to  a  Higgenson's  s^a'inge,  is  inserted,  and 
the  bladder  thoroughly  and  forcibly  washed  out  with  diluted  Thompson's 
fluid  (i  in  6  or  8,  p.  402);  or  mercury  perchloride  i  in  400c.  In  a 
week  or  ten  days  the  bladder  should  again  be  carefully  sounded,  and 


SUPRA-PUBIC  LITHOTOMY.  399 

examined  with  the  finger,  and  any  fragment  extracted,  this  being 
especially  needful  if  pain  has  persisted  after  the  operation.*  If  frag- 
ments still  persist  a  little  later,  an  evacuating-tube  and  washing-bottle, 
aided  if  necessary  by  a  llat-bladed  lithotrite,  must  be  employed.  I  may 
here  express  my  belief  that  multiple  calculi  are  not  quite  as  rare  as  has 
been  supposed.  (4)  Size  and  shape  of  the  stone.  ^Ir.  Erichsen  writes 
on  this  subject :  "  A  calculus,  about  an  inch  and  a  half  in  its  shorter 
diameter,  will  be  hard  to  extract  through  an  incision  of  the  ordinary 
length  (not  exceeding  eight  lines)  in  the  prostate,  even  though  this 
be  considerably  dilated  by  the  pressure  of  the  fingers ;  and  I  think 
it  ma}"  be  safely  said  that  a  calculus  two  inches  and  upwards  in 
diameter  can  scarcely  be  removed  by  the  ordinary  lateral  operation 
with  any  degree  of  force  that  it  is  safe  to  employ."  Most  will  agree 
with  Mr.  Cadge  that  stones  weighing  upwards  of  3  oz.  will  be  dealt  with 
b}"  the  improved  supra-pubic  method. 


SUPRA-PUBIC    LITHOTOMY  (Figs.  1 63- 1 66). 

Indications. — The  surgeon  A\ho  has  the  opportunity  of  becoming 
an  adept  in  the  use  of  the  lithotrite,  both  through  the  meatus  and 
through  a  perinseal  wound  (p.  421),  will  seldom  have  occasion  to  perform 
supra-pubic  lithotomy.  Where,  however,  there  has  been  no  such  oppor- 
tunity, this  operation  will  be  required  for  the  following  conditions. 
These  I  quote  from  the  concluding  portion  of  a  paper  which  I  read 
before  the  Royal  Medico-Chirurgical  Society  {Trans.,  vol.  Ixix.  p.  377). 

I.  '"That  supra-pubic  lithotomy,  as  recently  modified,  has  a  future 
of  renewed  usefulness  before  it,  and  that  while,  as  an  operation,  it  can 
never  contrast  with  the  rapid  brilliancy  of  the  lateral  operation,  it  will 
be  found  of  great  value  by  those  who  onl}'-  have  to  deal  with  stone 
occasionally,  and  by  those  who  find  themselves  face  to  face  with  calculi 
of  considerable  size  in  adults.  2.  That,  to  give  other  and  more  indivi- 
dual instances,  the  operation  will  be  found  useful  in  (a)  many  cases  of 
hard  stones  of  an  inch  and  a  half  in  diameter  ;  Qi)  in  multiple  hard 
stones  ;  (c)  in  cases  of  calculus  not  phosphatic,  occurring  with  enlarged 
prostate  ;  (d)  in  some  cases  of  foreign  body  in  the  bladder  with  abun- 
dant calculous  deposit  (Sir  H.  Thompson)  ;  (e)  in  cases  of  encysted 
stone. -|-  In  the  rarer  cases  of  (/)  a  state  of  urethra  which  will  not  admit 
the  use  of  a  lithotrite  or  a  grooved  staff.  .  .  .  ."  To  these  should  be 
added,  (cf)  in  cases  where  the  stone  is  associated  with  enlarged  prostate 
(p.  41 1).  The  siipra-pubic  opening  will  here  be  convenient  for  removing 
portions  of  prostatic  tissue  as  well  as  the  stone. 

The  greater  trouble  and  the  longer  time  which  this  operation  entails, 
both  during  its  performance  and  afterwards,  will  not  be  grudged  in 


*  Kecurrence  of  stone  within  two  years  almost  alwaj^s  means  that  a  fragment  has 
been  left  after  the  operation.  No  greater  disappointment  than  this,  both  to  the 
surgeon  and  patient,  can  happen.  No  one,  probably,  has  cut  fifty  patients  without 
having  to  admit  and  lament  its  occurrence,  but  it  is  especially  liable  to  occur  to  the 
inexperienced  (Cadge). 

f  Much  iiseful  information  may  be  gathered  from  a  paper  by  Mr.  Bruce  Clarke 
(^Brit.  Med.  Journ.,  May  13,  1899),  in  which  an  account  is  given  of  twenty-seven  cases 
of  encysted  vesical  calculus. 


400 


OPERATIOXS  ON  THE  ABDOMEN. 


these  daj^s,  when  it  is  so  much  the  rule  to  pay  attention  to  the  details 
of  surgery.  Only  time  and  a  larger  collection  of  cases  will  show  how 
far,  with  much  simpler  structures  to  cut,  with  these  brovight  safely  into 
reach,  and  with  modern  antiseptic  details  at  hand  in  the  after-treatment, 
this  lithotomy  is  safer  than  the  far  more  brilliant  lateral  one. 

Details  of  the  Operation.* 

A.  Distension  of  the  Rectum. — The  utility  of  this  is  doubtful, 
except  in  certain  special  cases  in  which  it  is  desirable  to  raise  the  base 
of  the  bladder  and  bring  it  as  much  within  reach  as  possible,  e.(j.,  in 
operations  for  tuberculous  disease,  and  for  the  removal  of  tumours  from 
the  base  of  the  bladder.  For  the  effect  of  rectal  distension  is  chiefly  to 
raise  the  bladder  bodily  in  a  direction  upwards  and  forwards,  and  hence 


Fig.  163. 


Oval  rectal  bags,  partly  distended.     A  child's  size  is  shown  below. 

after  incision  to  make  the  base  more  prominent  and  easier  to  reach  ;  the 
effect  as  regards  the  supra-vesical  fold  of  peritoneeum  is,  on  the  other 
hand,  so  small  that  it  may  be  neglected.  Moreover,  the  procedure 
is  not  without  danger.  If  it  is  decided  to  make  use  of  rectal 
distension  the  bag  should  be  distended  as  required  after  the  parietal 
incision  has  been  made,  so  that  the  effect  ma}^  be  gauged  by  a 
finger  in  the  pre-vesical  space.  The  bag  used  for  this  must  be  (i)  of 
sufficient  strength,  and  (2)  of  appropriate  size.  Thus,  it  should  be  of 
as  soft  rubber  as  is  consistent  with  strength,  with  seams  as  little 
prominent  as  possible,!  and  flattened  rather  than  pyriform  in  shape. 

*  These  are  largely  taken  from  a  paper  of  mine  (^Brit.  Med.  Jonrn..  Oct.  23  and 
30,  1886). 

f  In  two  of  my  earlier  cases  a  little  blood-stained  mucus  followed  the  withdrawal  of 
the  empty  bag ;  no  ill  results  ensued,  and  as  this  has  not  occurred  in  the  later  cases  I 
think  it  may  be  attributed  to  the  use  of  the  earlier  bags  of  pyriform  shape,  stout 
rubber,  and  prominent  seams.  When  a  bag  has  not  been  obtainable  the  lingers  of  an 
assistant  may  be  used  instead. 


SUPEA-PUJ3IC  LITHOTOMY. 


401 


(3)  The  amount  of  fluid.  A  flat,  oval  bag  (Fig.  163),  well  coated  with 
eucalyptus  and  vaseline,  entirely  emptied  of  air  and  folded  up,  is 
introduced  well  above  the  sphincters  (the  bowels  having,  of  covirse, 
been  well  emptied).  It  is  then  carefuU}^  distended  by  means  of  an 
easily  working  syringe  with  water  varying  in  amount  from  2  J  to  3  oz. 
in  a  child  of  five,  to  10  or  12  oz.  in  an  adult.  Sir  H.  Thompson  gives 
the  amount  in  the  adult  as  12  to  14  oz.  I  would  advise  operators  to  be 
content  with  the  smaller  amount  of  8  or  10  oz.,  adding  a  little  more 
later  on,  if  needful,  and  only  to  use  the  larger  amounts  in  special  cases 
— e.fj.,  large  stones,  doubtful  cases,  or  where  a  growth  is  present  and  it 
is  desired  to  give  extra  elevation  and  steadying  to  the  bladder. 

Fig,  164. 


Sagittal  median  frozen  section  through  the  pelvis  of  a  j'oung  man,  the 
bladder  being  distended.     (C.  Langer.) 


B.  Distension  of  the  Bladder. — Either  water  or  air  may  be  used 
for  this  purpose,  the  chief  advantages  claimed  for  the  latter  being 
(i)  that  its  buoyancy  tends  to  raise  the  bladder  up  to  the  surface, 
wliereas  the  weight  of  water  tends  to  drag  it  downwards  towards  the 
l)elvis  ;  (2)  being  compressible,  it  is  less  liable  to  do  damage  when  the 
bladder  walls  are  contracted  and  rigid;  (3)  there  is  no  flooding  of  the 
wound  Avhen  the  bladder  is  incised,  and  therefore  less  liability  of 
infection  of  the  peri-vesical  cellular  tissue. 

The  air  may  be  conveniently  introduced  by  means  of  a  bicycle  pump 
attached  to  the  catheter  by  means  of  a  length  of  rubber  tubing,  no 
measurement  of  the  quantity  used  being  necessary  when  the  plan 
advised  below  is  adopted. 

If  distension  with  water  is  preferred  to  air,  either  Thompson's  fluid 
VOL.  II.  26 


402 


OPERATIONS  ON  THE  ABDOMEN. 


(borax,  i  pt. ;  glycerine,  2  pts.  ;  water,  2  pts.)  diluted  one  in  six, 
carbolic  acid  one  in  eighty,  or  perchloride  of  niercur}-  one  in  4000  may 
be  used.  This  should  be  introduced  b}^  means  of  an  irrigator  raised 
about  a  foot  above  the  level  of  the  patient's  abdomen,  in  this  way  a 
safety-valve  is  provided  against  any  sudden  rise  of  pressure  within  the 
bladder  if  any  straining  takes  place.  If  the  plan  advised  below  is 
adopted  it  is  not  necessary  to  measure  the  quantity  of  liquid,  but  if  it 
is  preferred  to  introduce  this  first  it  must  be  measured,  in  this  case 
8  to  10  oz.  for  an  adult,  and  a  smaller  amount  for  a  child  will  be  found  to 
suffice  ;  larger  quantities  should  not  be  used  for  fear  of  causing  damage 

Fig.  165. 


Sagittal  median  frozen  section  of  male  pelvis,  with  distension  of  bladder 
and  rectum.     (Garson.) 


from  over-distension.  The  safest  plan  is  to  carry  out  the  distension  of  the 
bladder  after  the  incision  has  been  carried  down  to  the  transversalis  fascia 
and  the  wound  well  retracted,  as  advised  by  Tilden  Brown  (Ann.  of 
Surg.,  vol.  xxv.  p.  141).  The  air  or  antiseptic  solution  can  then  be 
gentl_y  and  slowly  introduced,  and  its  effect  gauged  by  the  eye  and  the 
finger  placed  on  the  bladder.  In  this  way  the  supra-vesical  fold  of  the 
peritonteum  may  be  raised  to  the  desired  extent  without  the  slightest 
risk  of  causing  damage  from  over-distension. 

C.  The  Operation  Itself. — The  pubes  having  been  shaved,  the  knees 
slightly  flexed,  and  the  shoulders  a  little  raised,  an  incision  is  made 
about  three  inches  long,  exactly  in  the  middle  line  and  ending  over  the 
upper  border  of  the  pubes.  The  subcutaneous  fat,  often  plentiful  in 
amount,   having  been  divided,  and  any  vessels   secured  with  Spencer 


SUPRA-PUBIC  LITHOTOMY.  403 

Wells's  forceps,  the  linea  alba  is  identified.*  nicked,  and  slit  up  for  two 

or  three  inches.     The  transversalis  fascia  is  then  picked  up  at  the  lower 

angle  of  the  wound  and  divided.     The  retractors  now  drawing  the  edges 

of  the  wound  well  apart,  a  layer  of  loose  tissue  and  of  fat.  often  abundant. 

and  frequently  having  large  veins  in  it,  will  next  come  into  view,  lyino- 

over  and  concealing  the  bladder.     This  must  be  torn  through  carefully 

and  as  cleanh'  as  possible  with  the  point  of  the  director.     Any  veins 

which  cross  the  wound  (and  a  transverse  branch  lies  often  just  opposite 

the  site  of  puncture  into  the  bladder)  should  be 

secured  with  forceps.     If  one  is  opened  at  this  Fig.  166. 

stage,  the  field  of  the  operation  will  be  obscured 

by  most  troublesome   hgemorrhage.t     This  must 

be  arrested    by  pressure-forceps,  which  act  also 

as  retractors,  by  sponge-pressure,  or  a  very  hot 

antiseptic  lotion — e.g.,  hydr.  perchl.    i   in  4000 ; 

prolonged  manipulation  in  arresting  haemorrhage 

here  may  be  the  cause  of  that  cellulitis  later  on 

which  is  so  much  to  be  deprecated.     The  anterior 

surface  of  the  bladder  will  now  be  recognised  by 

its  pink  colour,  the  fibres  of  the  detrusor  urinse, 

and  by  its  fluctuating  under  the  finger.     Veins 

often    are  met  with  again  here  on  the    bladder 

itself,   longitudinal,   transverse,  and  occasionally 

plexiform.      Great    care   must   be    taken   not    to 

open   up  the  fattv  connective  tissue  which  lies       Supra-pubic   lithotomy 

between  the  anterior  surface  of  the  bladder  and    if  "si«°'  seven  days  after 

^1  ,  ,  ,  ,,  ,      .  r.  r.     the   operation.     Only  the 

the  pubes.      A  spot    on  the  anterior  surface  of    ^^^^^^  p^,^  ^f  the  wound 
the    bladder    having   been   chosen    about    three-    ^-as  sutured. 
quartei's    of    an    inch|    above    the    pubes.    it    is 

punctured  (a  hook  being  used  if  thought  desirable),  and  the  left  index 
finger  at  once  introduced  to  feel  for  the  stone.  The  finger  at  the 
same  time  keeps  the  bladder  hooked  up,  and  prevents  it  settling  back 
into  the  pelvis  as  the  bladder  collapses.  The  stone  is  best  removed  by 
two  fingers,  or,  if  preferred,  by  forceps  or  scoop.  The  fingers,  if  suc- 
cessful, have  the  advantage  of  not  risking  any  injury  to  the  mucous 
membrane.     Kemoval  of  the  stone  is  not  always  eas}' ;  it  falls  back  into 


*  If,  instead  of  exactly  hitting  off  the  linea  alba  at  once,  the  surgeon  exposes  fibres 
of  a  rectus  or  pyramidalis.  he  should  go  straight  on  through  these  with  a  director. 
Any  prolonged  search  for  the  linea  alba  will  leave  frayed  fibrous  tissue,  which  will 
slough  tediously,  and  become  coated  with  phosphatic  deposit  if  the  urine  be  amnioni- 
acal.  If  the  muscles  are  thus  torn  through,  it  must  be  remembered  that  they  lie  on 
the  fascia  transversalis  ;  there  is  no  sheath  behind  them. 

f  M.  Guyon  in  his  second  case  met  with  most  profuse  haemorrhage  :  ••  Nous  essay- 
ilmes,  mais  assez  vainement.a  nous  opposer  a  Tenvahissement  de  toute  la  plaie  par  une 
nappe  de  sang  sans  cesse  renouvelee."  After  repeated  and  fruitless  attempts  to  arrest 
this  haemorrhage,  the  bladder  was  opened  and  the  stone  removed.  The  hiemorrhage 
ceased  entirely  on  the  removal  of  the  rectal  bag.  The  patient,  aged  69,  died  with 
purulent  infiltration  of  the  sub-peritoneal  connective  tissue.  Such  severe  haemorrhage 
is  very  rare. 

J  The  spot  chosen  must  not  be  too  low,  or  infiltration  may  take  place  into  the  cavum 
Retzii  behind  the  pubes ;  if  too  high,  drainage  will  be  interfered  with  and  the  peri- 
tonaeum endangered. 


404  OPERATIONS  OX  THE  ABDOMEN. 

the  fundus,  or  into  sulci  on  either  side  of  the  part  raised  by  the  bag,  if 
one  has  been  used.  As  soon  as  the  calculus  is  removed  and  the  bladder 
thoroughly  explored,  the  fluid  should  be  set  running  from  the  rectal  bag, 
as  emptying  this  takes  some  time. 

Great  difficulty  may  be  met  with  in  removing  an  enc^^sted  calculus, 
owing  to  the  fact  that  the  stone  usually  entirely  fills  the  sac,  the  neck 
of  which  is  frequently  quite  narrow.  If  the  neck  cannot  be  sufficiently 
dilated  to  deliver  the  stone,  whole,  through  this,  the  plan  recommended 
by  Hurry  Fenwick  (Medical  Annual,  1901)  may  be  made  use  of.  It  is 
described  as  follows  : — "  If  there  is  a  projecting  nose,  it  is  snapped  off' 
and  removed — if  no  dumb-bells  exist,  then  the  tiny  aperture  must  be 
located — slightly  dilated  by  the  point  of  the  forefinger,  and  if  possible 
the  stone  must  be  freed  in  its  sac.  A  caisson  or  speculum  should  then 
l)e  passed  on  to  the  apei'ture,  a  beam  of  light  thrown  along  the  channel 
to  expose  the  white  surface  of  the  stone,  a  blunt  graving  tool  or  chisel 
being  guided  on  to  it  under  control  of  the  eye.  The  assistant  now 
])asses  his  finger  into  the  rectum,  and  supports  the  stone  from  behind, 
while  the  surgeon  steadies  the  point  of  the  chisel  on  the  stone,  and  ta]js 
its  head  smartly  with  the  mallet.  The  stone  is  fractured,  as  it  is  cliiefl}" 
phosphatic  material.  With  a  little  manipulation  the  stone  is  turned, 
another  section  is  made,  and  so  on,  until  the  pieces  can  be  safely  pulled 
through  the  orifice  of  the  sac  into  the  caisson  and  out." 

The  question  now  arises  of  closinrj  the  openinrj  n-ith  sutures  or  leaving  it 
open,  in  part  at  least. 

The  drainage  of  the  bladder  by  a  catheter,  in  the  urethra,  or  by  suction 
and  syphonage  (p.  383)  is  so  difficult,  the  patient's  condition  so  very  un- 
satisfactory* for  the  first  \\eek  or  so,  owing  to  the  constant  soakage 
in  spite  of  voluminous  dressings,  that  wherever  it  is  possible  the  bladder 
opening  should  be  closed  by  sutures.  One  of  the  first  to  adopt  this  plan 
successfully  was  Dr.  L.  S.  Pilcher,  of  New  York  :  a  catheter  was  used 
till  the  ninth  day,  the  patient,  an  adult,  went  out  on  the  fourth,  and  on 
the  fourteenth  day  was  shown  to  the  New  York  Medical  Society,  primary 
union  having  taken  place  throughout  the  whole  extent  of  the  wound, 
without  unpleasant  symptoms  of  any  kind.  Mr.  R.  W.  Parker  had  an 
equalh^  successful  case  in  a  child  aged  3.  There  have  been  a  number  of 
others.  Mr.  Anderson,  of  Nottingham  {Lancet,  vol.  i.  1890,  p.  898). 
sutured  the  bladder  in  a  boy  aged  10.  Acute  pneumonia  complicated 
the  after-treatment,  and  on  the  night  of  the  fourth  day  (the  superficial 
sutures  being  removed  and  the  wound  healed)  prolonged  coughing  tore 
open  the  wound.  The  case  did  well.  Mr.  Pollard  described  three  cases 
in  which  the  bladder  was  sutured  after  sui:)ra-pubic  lithotomy  in  children. 
Urine  leaked  through  in  each  case  on  the  third  day.  All  did  well.  In 
a  ver}'  interesting  paper  by  Mr.  Bond,  of  Leicester  {Lancet,  vol.  ii.  1889, 
]>.  260),  it  will  be  seen  that  in  three  out  of  four  cases  in  which  the 
bladder  had  been  sutured,  some  urine  escaped  once  about  twelve  hours 
after  the  operation.      This  did  not  delay  the  union.     A  single  row  of 

*  This  is  especially  the  case  in  elderly  flabby  patients  with  damaged  kidneys,  and 
unsatisfactory  vital  power  and  will.  Such  tend  to  become  apathetic,  to  lie  help- 
lessly on  their  backs  down  in  the  bed,  thus  easily  getting  stasis  in  their  lung  bases 
and  broncho-pneumonia,  together  with  a  low  septic  condition  of  the  wound.  The 
nursing  of  such  cases  is  greatly  helped  by  suture  of  the  wound,  and  thus  keeping  the 
patients  dry. 


SUPEA-PUBIC  LITHOTOMY.  405 

L^embert's  sutures  put  in  efficiently  (p.  228)  will  suffice.  If  a  double 
row  is  used,  the  mucous  membrane  is  first  drawn  together  by  a  con- 
tinuous suture  of  chromic  gut,  and  then  some  interrupted  sutures,  not 
going  deeper  than  the  muscular  coat,  are  introduced. 

Sutures  should  not  be  employed  (i)  where  there  is  cystitis,  and  the 
urine  ammoniacal,  (2)  where  the  bladder  is  irritable,  thickened,  and  the 
better  for  drainage,  (3)  where  the  extraction  is  difficult  and  prolonged, 
and  the  parts  necessarily  bruised,  (4)  where  there  is  any  reason  to 
expect  bleeding ;  in  such  cases  the  clots  will  cause  violent  tenesmus, 
and,  probably,  giving  way  of  the  sutures,  (5)  where  there  is  any  stricture 
or  an  irritable  condition  of  the  urethra  sutures  are  inadmissible. 

Where  sutures  are  not  used,  in  order  to  prevent  extravasation,  the 
cut  edges  of  the  bladder  should  be  sutured  with  fine  catgut  to  the 
fascial  and  deeper  edges  of  the  wound,  two  or  three  sutures  being- 
placed  on  either  side,  and  one  below  at  the  lower  end  of  the  incision  so 
as  to  shut  off  the  tissues  behind  the  pubes. 

Two  or  three  buried  catgut  sutures  then  draw  the  linea  alba  together 
above,  the  edges  of  this  having  been  trimmed  and  pared,  while  three  or 
four  more  unite  the  skin.  Iodoform  and  collodion  should  be  brushed 
over  the  united  portion  of  the  wound,  and  the  bladder  should  be  drained 
by  Mr.  Cathcart's  method  (p.  383).  If  this  has  not  been  provided, 
a  large  Thomson's  supra-pubic  tube  should  be  inserted,  and  every 
attempt  made  by  a  regular  supply  of  dry  dressings,  and,  after  the  first 
twenty-four  hours,  turning  the  patient  on  his  sides  for  a  few  hours 
alternately,  to  prevent  any  part  becoming  sore  from  the  constant 
soaking.  But  if  the  bladder  is  not  sutured,  only  some  such  method  as 
Mr.  Cathcart's  will  keep  the  parts  dry  and  save  the  patients  from  the 
great  risk  of  extravasation.  Where  sutures  are  used  it  will  be  well 
not  to  unite  the  linea  alba  and  skin  below.  For  the  first  few  days  it 
Avill  be  unwise  to  trust  to  the  patient's  voluntary  power  of  expulsion, 
and  if  the  catheter  becomes  plugged,  or  if  it  is  not  passed  just  Avhen 
required,  some  urine,  possibly  septic,  may  be  forced  out  between  the 
sutures  before  the  bladder  wound  is  foially  closed,  a  process  which  must 
take  two  or  three  days.  If  this  extravasation  take  place  deep  down  in  a 
wound  like  this,  where  the  superficial  parts  have  been  closed,  there 
is  the  gravest  peril  of  a  fatal  issue  from  septic  purulent  infiltration  of 
the  connective  tissue  of  the  cavum  Retzii,  pelvis,  and  abdominal  wall. 

A  few  words  may  be  said  here  about  the  peritonceum.  With  siich  dis- 
tension of  the  bladder  as  has  been  advised,  with  an  incision  not  begun 
too  high  up  and  carried  well  down  over  the  pubes,  with  a  moderate 
incisicn  into  the  bladder,  it  is  most  unlikely  that  anything  will  l)e  seen  of 
the  peritonaeum.  It  may  be  very  indistinctly  felt  at  the  upper  part  of 
the  wound,  but  this  is,  usually,  all. 

If,  after  careful  distension  of  the  bladder  the  peritonaeum  still  seems 
to  encroach  too  far  upon  the  anterior  surface  of  the  bladder,  it  may  be 
pressed  upwards  and  held  out  of  the  way  by  one  or  two  fingers  of  an 
assistant,  or,  if  needful,  gently  peeled  upwards  off  the  bladder  with 
a  steel  director.*     In  elderly  people  with  lax  tissues  and  large  stones 


*  In  only  three  of  my  fourteen  cases  did  I  have  any  trouble  with  the  peritonaeum. 
To  give  one  instance,  in  an  elderly  patient  of  Dr.  Bell's,  of  Blackheath,  with  two  lithic 
acid   calculi   each  weighing   i    oz.,  the   peritouasuni  almost  reached  the  level  of  the 


406  -      OPERATIOTs^S  OX  THE  ABDOMEN. 

requiring  free  incisions,  the  peritonsenm  covered  with  its  fatty  tissue  is 
more  likel}^  to  be  seen  rising  and  falling  in  the  upper  angle  o^"  the 
Avound. 

If,  what  is  most  unlikely  with  the  recent  improvements  in  the  opera- 
tion, the  peritonaeum  should  be  punctured  before  the  bladder  is  opened, 
the  puncture  should  be  picked  up  and  tied  around  with  fine  silk  or 
chromic  gut.  If  the  opening  is  more  than  a  puncture  the  cut  edges  of 
the  peritonaeum  should  be  sutured  to  the  edges  of  the  external  woimd. 
and  the  bladder  not  opened  for  three  or  four  days  {Bruce  Clarke,  Brit. 
Med.  Journ.,  vol.  i.  1890,  p.  240). 

If  the  opening  is  made  after  the  bladder  is  opened,  the  surgeon  must 
decide,  according  to  the  amount  and  character  of  the  urine  which  has 
escaped,  between  suturing  the  opening  and  enlarging  it  upwards,  so  as 
to  thoroughly  sponge  out  or  cleanse  by  irrigation  with  a  2  per  cent, 
solution  of  boracic  acid,  the  ]:)eriton£eal  cavity.  But  these  accidents  are 
most  unlikely  nowadays. 

I  have  now  operated  by  this  method  fourteen  times  in  the  last  few  years, 
the  patients  ranging  from  3  to  62  years.  Four  only  of  the  stones  were 
large.  Two  were  just  over  2  oz.,  a  third  was  5  oz.  ;  in  the  fourth,  a  young- 
woman,  the  stone,  formed  round  a  hairpin,  weighed  6  oz.  In  five  thej 
were  multiple.  In  seven  the  urine  was  alkaline  and  foul.  Four  cases 
were  fatal — the  sixth,  a  lad  of  19,  an  orphan,  in  wretched  condition  of 
body,  and  in  much  misery  from  pain.  Perhaps  I  should  have  done  more 
wisely  to  have  waited  longer,  in  order  to  feed  him  up  before  operating. 
His  pain,  however,  A\as  so  severe  that  I  operated  a  week  after  his  admis- 
sion into  the  hospital.  He  did  excellently  for  forty-eight  hours,  then 
symptoms  of  pelvic  cellulitis  set  in,  jDroving  fatal  on  the  fourth  day. 
The  other  case  was  one  of  multiple  stones  in  a  man  of  58,  much  run 
down- in  strength.  I  removed  eight  calculi,  composed  chiefly  of  urates. 
The  patient  sank  shortly  after.  His  kidneys  proved  to  be  in  an  advanced 
stage  of  granular  degeneration.  Two  other  patients,  elderlj'^  men,  died 
of  kidnev  failure,  one  on  the  fourth  day,  the  other  twentj^-two  days  after 
the  operation. 

While  on  some  points  connected  with  the  operation  my  mind  remains 
open,  I  am  strongly  of  opinion  that,  with  carefulness,  it  is  a  safer  opera- 
tion than  the  lateral  method  for  those  who  only  perform  lithotomy 
occasionalh^,  and  for  large  stones — e.<j.,  over  i  oz.  I  am  certain  that  no 
benefit  is  to  be  gained  by  substituting  it  for  the  lateral  in  the  case  of 
children. 

MEDIAN    LITHOTOMY. 

Disadvantages. 

I.  It  gives  \eYj  little  room,  and  is  unsuited  to  any  save  the  smallest 
■stones.     2.  The   wound   being   small,    the    surgeon   cannot    bury   his 

symphysis.  It  was,  however,  easily  detached  from  the  bladder  and  held  up  with  a 
retractor.  I  closed  the  upper  part  of  the  wound  carefullj^  over  it,  and  sutured  the 
edges  of  the  bladder  to  the  deep  part  of  the  wound.  A  good  recovery  followed  in  this 
and  the  other  two  cases,  which  were  similar.  At  the  Congress  of  German  Surgeons  in 
1886,  Gussenbauer,  Sonnenberg,  and  Kramer  mentioned  cases  in  which  the  peritonaeum 
was  found  adherent  to  the  symphysis.  In  one  case  it  was  opened  with  fatal  results  ; 
in  another,  the  opening  was  sewn  up  and  the  peritonaeum  safely  separated  from  the 
pubes. 


MEDIAN  LITHOTOMY 


407 


knuckles  in  it,  or  reach  the  bladder  as  easily  as  in  the  case  of  the  larger 
lateral  wound  (Cadge).     3.  The  rectum  on  the  one  hand,  and  the  bulb 
on  the  other,  are  in  greater  danger  than  by  the  lateral  method  (Cadge). 
4.  Troublesome  bleeding  is  more 
frequent  (Cadge).  ^^*^'-  '^~- 

Mr.  Cadge,  having  operated 
on  fifty  or  sixty  cases  by  the 
median  method,  has  given  it  up 
for  the  above  reasons,  and  also 
because  his  mortality  has  been 
rather  higher. 

Advantages. — Recovery  is 
often  extremely  rapid  ;  the  urine 
quickly  resumes  its  natural  route ; 
and  the  wound,  instead  of  gaping 
and  healing  slowly  as  the  lateral 
wound  does,  heals  almost  by  first 
intention.* 

The  above  do  not,  however, 
compensate,  in  Mr.  Cadge's 
opinion,  for  the  disadvantages. 
He  would  avoid  it,  especially  in 
children,  in  whom  it  is  by  some 
preferred,  as  in  them  a  free  in- 
cision is  necessary  to  facilitate 
the  passing  of  the  finger  into  the 
bladder,  while  here  the  limit  of 
space  for  the  knife  is  very  small 
indeed. 

The  operation  is  suited  for 
prostatic  calculi,  but,  if  these  are 
associated  with  any  larger  one  in 
the  bladder,  the  surgeon  must 
either  crush  this  before  he  can  extract  it  tlu'ough  hi 
perform  a  supra-pubic  operation. 

Operation. — If  a  curvedf  stafi"  be  used,  one  with  a 


Median  lithotomy.  The  left  fore-finger  being- 
introduced  along  the  director,  which  was 
passed  into  the  bladder  before  the  withdrawal 
of  the  staff.     (Heath.) 


small  incision,  or 


wide  groove  is 


*  Dr.  W.  T.  Briggs,  of  Nashville  (Trans.  Amer.  Surff.  Assoc,  vol.  v.  p.  127),  thus  sums 
up  the  advantages  of  median  lithotomy:  (i)  It  opens  up  the  shortest  and  most  direct 
route  to  the  bladder.  (2)  It  divides  parts  of  the  least  importance.  (3)  It  is  an  almost 
bloodless  operation.  (4)  It  affords  a  passage  for  any  calculus  which  can  be  safely 
extracted  through  the  perinieum.  (5)  It  affords  the  best  passage  for  the  fragmenta- 
tion of  unusually  large  calculi.  (6)  It  reduces  the  death-rate  to  a  minimum.  In  answer 
to  the  objection  to  the  median  operation  that  it  is  unfitted  for  the  extraction  of  large 
stones,  Dr.  Briggs  states  that  by  making  it  a  medio-bilateral  operation  (^vidc  infra'), 
as  large  stones  can  be  removed  by  it  as  can  be  extracted  bj'-  the  lateral  method.  Since 
adopting  the  above  modification,  Dr.  Briggs  has  had  the  following  excellent  results  :  Of 
the  first  seventy-four,  none  died.  Then  two  died,  but  one  of  these  had  a  pelvic  abscess 
before  the  operation,  and  the  other  died  at  the  end  of  three  months  with  phthisis,  and 
the  wound  unhealed.     Since  then  Dr.  Briggs  has  had  forty-six  cases  with  one  death. 

t  Mr.  Erichsen  recommends  a  rectangular  staff,  the  angle  of  which  rests  against  the 
apex  of  the  prostate,  and  is  thus  much  easier  to  find  in  the  perinieum.  The  special 
staff  is,  however,  often  difficult  to  introduce,  and  a  curved  one,  held  so  as  to  project  its 
curve  in  the  perinieum,  will  be  easily  found. 


4o8  OPERATIOXS  OX  THE  ABDOMEN. 

chosen,  and  passed  and  held\A'ith  its  handle  inclined  towards  the  umbili- 
cus (p.  394),  the  patient  being  in  lithotomy  position.  The  surgeon 
passes  his  left  forefinger  into  the  rectum  so  as  to  steady  with  its  tip  the 
staff  in  the  membranous  urethra  and  also  to  guard  the  rectum  from 
puncture,  while  at  the  same  time  note  is  taken  of  the  depth  of  tissues 
between  the  knife  and  the  finger.  A  straight  and  very  sharp  bistoury' 
is  then  pushed,  with  its  back  downwards,  through  the  skin,  half  an  inch 
above  the  anus,  straight  on  into  the  groove  in  the  staff,  which  is  now 
held  well  hooked  up  against  the  pubes.  The  knife,  having  distinctly 
exposed  the  groove,  is  pushed  a  little  onwards  so  as  to  nick  the  apex  of 
the  prostate,  and  next,  as  it  is  Avithdrawn,  it  is  carried  upwards  in  the 
raphe  so  as  to  divide  the  soft  parts  for  one  inch  or  more,  according  to 
the  size  of  the  stone.  The  finger  would  now  be  passed  into  the  bladder, 
and  the  staff  withdrawn.  As,  however,  the  staff  occupies  too  much  room 
in  the  limited  wound  to  allow  of  this,  a  director  is  passed  in  along  the 
groove,  the  staff  withdrawn,  and  then  the  finger  introduced  along  the 
director  through  the  neck  of  the  bladder.  This  is  dilated  sufficiently, 
and  the  scoop  or  forceps  introduced. 

Some  surgeons  prefer  to  make  the  incision  from  above  downwards, 
but  cutting  from  belo\A'  iipwards  would  seem  better  to  protect  the  bowel. 

If  a  straight  staff  be  used,  the  surgeon  introducing  his  knife  as  above, 
and  having  cut  upon  the  staff  distinctly  both  to  himself  and  the  assistant 
who  is  holding  it,  takes  it  into  his  left  hand,  and,  having  brought  it 
down  into  an  oblique  position,  runs  his  bistoury  along  the  groove  so  as 
to  nick  the  prostate  ;  the  enlargement  of  the  wound  and  the  rest  of  the 
operation  are  conducted  as  above. 

Where  the  stone  is  too  large  to  be  extracted  by  the  ordinary  median 
operation,  the  medio-bilateral  modiflcation  introduced  by  Gouley, 
1828,  and  used  so  successful!}^  in  America  by  Dr.  Briggs,  should  be 
employed.  It  consists  in  making,  after  a  longitudinal  incision  in  the 
raphe,  a  slight  bilateral  cut  in  the  elastic  ring  at  the  neck  of  the  bladder 
and  the  prostate. 

Complications  and  Causes  of  Death  after  Lithotomy. —  i.  Shock. 
— This  is  rarely  severe,  save  in  patients  much  pulled  down,  and  after 
prolonged  operations.  Children,  as  a  rule,  however  reduced,*  rally  well 
after  the  operation  (Sir  J.  Paget,  Clin.  Essays,  p.  404).  2.  Haemor- 
rhage.-— ^If  milder  methods  fail  this  is  best  met  by  plugging  the  wound 
with  the  umbrella-plug,  or  by  leaving  in  situ  a  pair  of  Spencer  Wells's 
forceps,  which  will  also  aid  the  drainage.  3.  Pelvic  cellulitis.- — -This, 
the  most  frecpient  cause  of  death,  is  due  either  to  extravasation  of  urine, 
probably  septic,  or  to  laceration  of  the  deep  parts,  or  both.  It  usually 
comes  on  within  forty-eight  hours.  4.  Peritonitis. — Usually  combined 
A\ith  the  above.  5.  Septic  complications. — SepticEemia  may  occur 
early  with  pelvic  cellulitis.  Pyaemia,  on  the  other  hand,  may  come  on 
later.  6.  Surgical  kidney.  7.  Retention  of  urine. — Common  enough 
a  few  days  after,  from  swelling  of  the  parts.  Karely  more  serious 
8.  Suppression  of  urine.  9.  A  sloughy,  phosphatic  state  of  the  wound. 
10.  Sloughing  of  the  rectum  (p.  396).      ii.  Cystitis. — Rare.      12.  Epi- 


*  Occasionally,  however,  even  nowadays,  where  the  history  is  of  long  standing  and 
the  kidneys  much  impaired,  they  are  too  far  gone  for  operation.  See  a  case  by 
Mr.  Hutchinson  (^Clin.  Surrj.,  pi.  Ixxvi.  vol.  ii.  p.  126). 


LITIIOTRITY.— LITHOLAPAXY.  409 

didvmitis.      13.  Such  causes  as  tetanus.     Later  complications  rare,  but 
troublesome.      14.  Fistula.      15.  Incontinence.      16.   Sterility. 


LITHOTRITY— OPERATION  WITH  SEVERAL  SITTINGS- 
RAPID  OPERATION  WITH  ONE  SITTING  AND  EVACU- 
ATION—LITHOLAPAXY— PERINJEAL  LITHOTRITY. 

Choice   of  Operation— Lithotrity   or  Lithotomy.— It  is 

hoped  that  tlie  following  points,  while  they  do  not  in  the  least  exhaust 
the  subject,  will  be  found  of  practical  assistance  : 

1 .  Amount  of  experience  of  the  surgeon. ^ — -Every  attempt  should  be 
made  to  become  familiar  with  the  use  of  the  instruments,  both  outside 
the  bod}'  and  also  by  passing  a  lithotrite  for  examination  of  a  calculus 
whenever  one  is  felt  on  sounding.  No  surgeon  who  has  not  had  abun- 
dant opportunities  of  practising  the  needful  manipulations  will  do 
wisely  in  attempting  to  crush  a  hard  stone  which  weighs  an  ounce. 

2.  Size,  kind,  and  number  of  stones.  — As  to  size,  up  to  i  oz.  or  li  oz., 
it  is  probable  that,  with  the  majority  of  stones,  in  fairly  practised 
hands,  lithotrity  is  immensel}'  superior  to  lithotomy  as  far  as  imme- 
diate mortality  is  concerned.  I  use  the  term  "  immediate  "  advisedly, 
because  of  the  more  frequent  recurrence,  with  its  results,  after  lithotrity, 
and  would  refer  my  readers  to  the  remarks  on  this  point  at  p.  412. 
Much  larger  stones  may  be  successfully  crushed  by  an  experienced 
operator  with  the  specially  strong  instruments  now  made.  Freyer 
(Lancet,  Dec.  12,  1896)  gives  a  list  containing  thirty-one  cases  in  which 
the  stone  averaged  2  oz.  5  drs.  in  w^eight,  all  of  which  were  successfully 
crushed.  The  largest  stone  which  Fre^^er  has  crushed  weighed  6^  oz., 
the  operation  lasting  two  hours.  The  same  author,  moreover,  consi- 
ders that  in  all  cases  trial  should  be  made  of  litholapaxy  before  a 
cutting  operation  is  performed. 

Mr.  H.  Milton  ("'  Lithotrity,  Simple  and  Complicated,"  Lancet,  April 
and  May,  1896)  records  an  epoch-marking  case  in  which  he  crushed  a 
stone  (urates  and  phosphates)  weighing  over  12  oz.  The  operation 
lasted  two  hours,  and  an  especial  lithotrite  with  a  gape  of  five  inches 
was  used.  Such  an  operation  is,  of  course,  only  possible  for  an  expert 
with  especial  experience,  such  as  Mr.  Milton's  in  Egypt.  This  surgeon 
had  before  (St.  Tlios.  Hosp.  Beports.  1891)  referred  to  the  extraordiiiary 
tolerance  which  Orientals  show  to  all  operations  connected  with  the 
genito-urinary  apparatus. 

The  difficulty  of  a  decision  sometimes  met  with  here  is  well  expressed 
by  the  words  of  Sir  W.  Fergusson,  that  the  greater  is  the  experience  of 
the  surgeon  the  greater  will  sometimes  be  his  doubt. 

To  anyone  with  very  limited  experience  rashly  contemplating  an 
attack  upon  a  hard  stone  I  would  recall  Mr.  Milton's  words  (loc.  infra 
cit.)  :  "  During  the  first  twenty  minutes  of  a  long  crushing  most  men 
can  maintain  the  necessary  delicacy  of  manipiilation,  combined  with 
the  exercise  of  considerable  force ;  but  when  it  comes  to  working  at  the 
same  strain  for  a  second,  third  or  foiu-th,  or  even  fifth,  sixth  or  seventh 
period  condition  begins  to  tell  ....  this  force  has  to  be  exerted  with 
the  greatest  discrimination  and  the  greatest  patience."     In  addition  to 


41 0  OPERATIONS  OX  THE  ABDOMEN. 

the  above  must  be  remembered  the  frequent  introduction  and  with- 
di'awal  of  instruments,  lithotrite  and  evacuators,  and  the  result  upon  the 
neck  of  the  bladder  and  the  deep  urethra. 

More  im])ortant  than  the  size  of  the  stone  is  its  composition.  There 
is,  of  course,  no  comparison  between  a  pure  lithic  acid  or  oxalate  of 
lime  stone  on  the  one  hand  and  an  alternating  stone  with  a  good  deal 
of  phosphate  or  urates  in  its  composition,  as  a  test  of  skill  and  endur- 
ance both  on  the  part  of  the  surgeon  and  his  instruments.  Dr.  Kings- 
ton, of  Montreal  {Iniern.  Enci/cl.  of  Surg.,  vol.  vi.  p.  311),  in  his  article 
on  Lithotrity,  points  out  that  sometimes  the  apparent  softness  of  a 
stone  is  most  misleading. 

Having  found  an  enormous  stone  in  a  patient,  lie  employed  lithrotity,  as  the  stone 
seemed  soft.  After  getting  away  a  large  quantity  of  phosphatic  matter,  he  was  driven 
to  perform  lithotomy,  and  removed,  by  the  lateral  method,  a  calculus  weighing  over 
5  oz.,  consisting  mainly  of  oxalate  of  lime  and  uric  acid. 

There  are  several  other  fallacies  in  gaiujing  the  size  and  nurnher  of 
calculi.  Thus  the  lithotrite  may  again  and  again  seize  a  stone  which 
only  weighs  ^  oz.  in  its  long  diameter,  if  flattened,  of  two  inches. 
Testing  by  passing  a  staff  around  or  rubbing  it  over  a  calculus  is  often 
most  fallacious,  and  examining  per  rectum  may,  if  the  bladder  be 
thickened,  give  evidence  of  a  stone  apparently  much  larger  than 
it  really  is.  Mr.  Cadge  (loc.  supra  cit.)  points  out  a  fallacy  with  regard 
to  multiple  stones.  "  When  more  than  one  stone  is  present,  it  is 
customary  to  seize  one,  fix  it  in  the  instrument,  and  proceed  to  sound 
afresh  ;  this,  however,  may  mislead,  for  a  stone,  having  been  grasped 
by  the  tips  of  the  lilades  and  moved  about  in  the  bladder,  will  some- 
times rotate  a  little  in  the  blades  of  the  lithotrite  and  communicate  a 
p-ratinyf  feel  to  the  hand  which  is  very  like  touching  a  second  stone." 

3.  Condition  of  the  urethra. — Two  points  have  to  be  considered 
here — (a)  how  far  wi-ll  the  urethra  admit  instruments — i.e.,  how  far 
is  its  canal  normal  or  diminished  by  stricture ;  (6)  how  far,  even  if 
normal  in  calibre,  will  the  urethra  tolerate  instruments.  With  regard 
to  the  first,  a  stricture,  if  admitting  of  dilatation,  is  not  an  obstacle  to 
lithotrity;  on  the  other  hand,  an  old  stricture  with  surrounding 
induration  and  fistulae,  or  a  less  severe  form  which  produces  rigors  and 
fever  at  each  attempt  of  dilatation,  are  best  submitted  to  lithotomy, 
which  gives  the  best  chance  for  the  stone,  and  at  the  same  time  offers 
the  much-needed  relief  of  rest  to  the  stricture.  Mr.  Cadge  gives  the 
following  practical  hint  in  these  cases  of  stone  combined  with  stricture  : 
"  Sometimes  a  stone  is  detected  in  the  urethra  behind  the  stricture,  as 
well  as  one  or  more  in  the  bladder,  or  it  may  be  partly  in  the  bladder 
and  partly  in  the  urethra,  and  in  these  cases  median  lithotomy  will  not 
only  remove  the  stone,  but  may  go  far  to  remedy  the  stricture  by 
external  division." 

With  regard  to  an  irritable  urethra — i.e.,  one  A\'ithout  a  stricture  and 
only  admitting  instruments  with  the  aid  of  anaBsthetics — the  chief 
points  to  consider  are  the  size  of  the  stone  and  the  ability  of  the 
surgeon  to  deal  with  it  by  litholapaxy.  If  the  calculus  cannot  be 
evacuated  at  once,  or  requires  more  than  one  sitting,  lithotomy  should 
be  preferred,  owing  to  the  results  of  the  passage  of  instruments  and 
prolonged  voiding  of  fragments. 


LITIIOTEITY— LITirOLAPAXY.  41 1 

4.  Condition  of  the  prostate. — An  enlarged  prostate  is  of  great 
importance,  not  only  from  its  power  of  obstructing  the  operation, 
but  from  the  changes  which  it  brings  about  in  the  bladder.  Thus, 
it  interferes  with  the  efficient  use  of  instruments,  the  picking  up  of  a 
stone  even  with  the  blades  reversed,  and  the  finding  of  the  last 
fragment.  Again,  the  use  of  the  lithotrite  and  the  passage  of 
evacuating  tubes  readily  lead  to  ha3morrhage,  and  this  again  by  clots 
prevents  the  free  and  easy  use  of  the  evacuator.  Later  on,  phosphatic 
deposit,  imperfect  evacuation,  residual  urine,  and  recurrence  of  stone 
symptoms  are  all  frequent  accompaniments  of  enlarged  prostate. 

5.  Condition  of  the  bladder. — Formerl}'  it  was  held  needful  to 
operate  with  several  ounces  of  fluid  in  the  bladder,  and  some  suggested 
to  draw  off  the  urine  and  inject  8  or  10  oz.  of  fluid.  This  amount  has 
now  been  reduced  to  something  more  like  4  or  6  oz.  As,  if  the  urine 
is  healthy,  no  fluid  is  more  suited  to  the  bladder,  the  surgeon  should 
content  himself  with  following  Sir  H.  Thompson,  and  "ask  the  patient 
to  retain  his  ui'ine  for  a  little  less  than  his  accustomed  period  before 
the  sitting ;  that  is,  if  he  is  naturally  able  to  retaiia  his  urine  for  about 
an  hour,  he  is  requested  to  pass  it  forty  minutes  before  the  time  of  the 
visit." 

Some  other  changes*  in  the  bladder  require  mention,  (a)  Saccula- 
tion pouches  or  sacs,  whether  mere  hollows  behind  or  at  the  sides  of 
an  enlarged  prostate,  or  hernial  protrusion  of  the  mucous  membrane 
between  the  muscular  fibres,  may  be  the  starting-point  of  calculus 
by  entangling  debris  or  tiny  fragments.  In  Mr.  Cadge's  words  :  "  The 
imprisoned  fragment  first  fills  up  the  cyst,  then,  by  continual  accretion 
of  phosphates,  it  grows  up  into  the  bladder  like  a  mushroom,  and  is 
probably  again  and  again  nibbled  off  by  the  lithotrite,  each  time  with 
temporarv  benefit,  until  the  patient  dies,  worn  out  with  chronic  cystitis 
and  pyelitis.'"  Mr.  Cadge  goes  on  to  say :  "  By  turning  the  aperture  of 
the  evacuating  catheter  towards  these  pouches,  and  by  the  free  use  of 
the  aspirator  in  all  directions,  the  fragments  may  be  washed  out  of 
them  and  all  removed,  but  it  cannot  be  denied  that  it  is  always  a 
serious  matter  to  shatter  a  stone  into  innumerable  fragments  in  a 
bladder  of  this  description."  (h)  Atony,  whether  with  or  AAithout 
an  enlarged  prostate.  The  importance  of  this  is  ob\'ious,  as  tending  to 
recurrence  of  stone  by  some  small  fragments  not  being  expelled  in  spite 
of  the  vigorous  use  of  the  aspirator,  and  also  to  cystitis  from  imperfect 
emptying  of  the  bladder. 

6.  Condition  of  the  kidneys. — Here  I  may  again  quote  a  veteran's 
opinion,  that  of  Mr.  Cadge :  "  What  is  to  be  said  of  stone  complicated 
with  kidney  disease,  such  as  albuminuria  and  chronic  pyelitis  and 
atrophy  ?  In  these  cases  all  operations  are  fraught  with  danger,  but  it 
is  probable  that  the  least  danger  will  be  met  with  from  a  carefully 
conducted  one-sitting  lithotrity.    So,  too,  in  those  cases  of  constitutional 

*  Several  allied  conditions  exist  in  which  the  position  of  the  stone  is  complicated 
with  difficulties — e.r/.,  (i)  where  the  stone  has  been  partly  in  the  bladder  and  partly 
in  the  urethra.  (2)  The  stone  has  been  lodged  entirely  or  partly  in  a  diverticulum  of 
the  bladder.  (3)  The  stone  has  been  lodged  in  a  deep  pouch  behind  the  prostate. 
For  helpful  information  on  these  and  many  other  points  I  would  advise  my  readers 
to  consult  Mr.  H.  Milton's  paper  on  '•  Lithotrity  in  Cases  of  Stone,  Simple  and  Com- 
plicated," Lancet,  April  and  May,  1896. 


412  OPERATIONS   ON  THE  ABDOMEN. 

disease  combined  witli  stone,  such  as  diabetes,  tabes,  and  other  spine 
disease,  it  will  be  well  to  avoid  the  shock  and  haemorrhage  of  lithotomy, 
and  proceed,  if  any  surgical  proceeding  is  allowable,  by  lithotrity."'  The 
surgeon,  in  considering  an  operation  in  any  of  the  aloove  diseases,  will 
weigh  well  the  size  of  the  stone,  his  ability  to  cope  with  it  at  one 
sitting,  and  the  amount  of  suffering  which  it  causes  the  patient. 

7.  Age. — Here,    especially,    age    is    not   to    be    reckoned    by   years 
alone. 

Keourrence. — As  no  one,  to  my  knowledge,  has  spoken  out  on  this 
subject  with  such  helpful  candour  as  Mr.  Cadge,  with  his  experience  of 
300  cases  of  stone,  I  make  no  apology  for  quoting  once  more  from  his 
writings  (Brit.  Med.  Journ.,  July  3,  1886)  :  "  Although  the  immediate 
and  direct  mortality  of  lithotrity  is  small,  the  recurrence  of  stone 
is  lamentabl}^  frequent.  In  my  own  list  of  133  cases,  there  were 
eighteen  in  which  recurrence,  one  or  more  times,  took  j^lace,  being 
about  one  in  seven.  Sir  H.  Thompson,  with  a  much  larger  number  of 
cases,  gives  about  the  same  proportion.  I  am  disposed  to  infer, 
however,  that  reciirrence  is  more  frequent  even  than  this,  because  it  is 
not  likely  that  all  who  get  relapse  apply  to  the  same  surgeon  again. 
Living,  as  I  do,  in  a  local  centre,  and  drawing  cases  chiefly  from  a  limited 
ai-ea,  I  am  probably  more  able  to  trace,  and  more  called  on  to  treat  those 
who  suffer  a  second  and  third  time,  tiian  he  who  lives  in  the  metropolis 
and  draws  his  cases  from  great  distances.  Patients  may,  and  frequently 
do,  apply  to  the  same  operator  once  or  twice  ;  but,  after  a  time,  they 
either  apply  to  their  own  surgeon,  or  they  decline  further  treatment,  and 
too  often  their  subsequent  history  is  one  of  painful  endurance  of  chronic 
bladder  disease  and  gradual  exhaustion.  If,  moreover,  there  be  added 
to  the  list  those  numerous  cases  of  phosphatic  deposit  or  concretions  so 
frequently  noticed  after  lithotrity,  the  relapses  would,  I  believe,  reach  to 
nearly  20  per  cent.  This  seems  a  heavy  indictment  to  bring  against 
lithotrity,  but  I  am  afraid  there  is  no  gainsaying  it  ;  and,  if  so,  it  would 
be  wrong  to  pass  it  over  or  make  light  of  it.  Many  of  these  relapses 
might  be  prevented  if  the  patients  woidd  observe  directions  and  per- 
severe with  treatment.  It  certainly  is  so  with  the  unenlightened  and 
uncomplaining  hospital  patient.  Feeling  himself  well,  or  what  he 
considers  well,  he  goes  to  his  work,  and  neglects  the  use  of  the  catheter 
and  other  means  ;  and,  instead  of  returning  in  a  month  or  so  to  have 
his  cure  certified,  or  a  minute  remaining  fragment  removed,  he  toil& 
away  as  long  as  he  can,  and  returns,  perhaps  in  a  year  or  two,  with  a 
fresh  uric-acid  stone,  or  with  chronic  cystitis  and  a  phosphatic  one. 
The  educated,  sensitive  private  patient,  on  the  other  hand,  will  watch 
his  symptoms  narrowly,  and  return  if  the  slightest  indication  of  the  old 

mischief  should  reappear This  frequent  recurrence  must 

be  due  either  (i)  to  the  descent  of  a  fresh  stone  from  the  kidneys, 
or  (2)  to  a  fragment  of  stone  having  been  left  at  the  first  operation.  As- 
to  the  descent  of  a  fresh  stone  :  there  can,  of  course,  be  no  doubt  as  to 
the  occasional  occurrence  of  this  cause,  just  as  we  see  it  occur  after 
lithotomy.  The  bladder  being  entirelj^  cleared  of  stone,  there  will  be 
the  same  liability  to  the  descent  of  a  fresh  renal  calculus  after  one 
operation  as  after  the  other.  What  then,  let  me  ask,  is  the  fact  as 
to  lithotomy  ?  I  have  alread}^  shown  that  there  were  only  twenty- 
one  cases  out  of  more  than  looo  of  lithotomy  at  the  Norwich  Hospital  in 


LITHOTRITY— LITIIOLAP-IXY. 


413 


which  recurrence  was  clearly  traced  to  perfectly  fresh  formations, 
coming,  like  the  first,  from  the  kidney,  or  about  one  in  fifty ;  whereas, 
in  Sir  H.  Thompson's  list  of  about  600  persons  treated  by  lithotrity,  he 
mentions  sixty-one  cases  in  which  he  operated  twice  ;  nine,  three  times  ; 
three,  four  times,  and  two,  five  times — seventj-five  in  all,  or  about 
one  in  eight.  The  inference  from  these  data  seems  to  me  to  he 
inevitable,  that  relapse  of  stone  after  lithotrity  is  chiefly  due  to  other 
causes  than  the  descent  of  a  fresh  stone.  To  my  thinking  the  majority 
of  recurrences  is  caused  by  the  great  difficulty  in  ensuring  the  complete 
i-emoval  of  all  the  debris  ;  I  have  already  referred  to  this  in  old  persons 
with  enlarged  prostates  and  feeble  atonic  bladders,  and  it  is  this  class  of 
patients  who  are  especially  liable  to  relapse."  Mr.  Cadge  goes  on  to 
show  that  the  tendency  to  phosphatic  deposit  after  lithotrity  is  not  due 
to  vesical  incompetence  and  residual  urine  alone  without  some  over- 
looked fragment,  and  that  the  improved  method  with  repeated  washings 
will  still  fail  to  discover  a  last  fragment  in  some  bladders. 

More  recently  Mr.  Reginald  Hai-rison  has  given  (Lancet,  Nov.  12, 
1899)  an  analysis  of  iio  operations  for  stone,  loi  of  which  were  litlio- 
lapaxies.  Recurrence,  necessitating  further  operation,  took  place 
twenty-three  times,  i.e.,  in  nearly  23  per  cent.,  a  considerabh'  greater 
proportion  than  Mr.  Cadge  gives.  In  all  but  one  case  the  recurrence 
was  associated  with  enlarged  prostate.  Mr.  Harrison  considers  that 
this  is  accounted  for  in  several  ways,  partly  by  the  fact  that  debris  may 
be  left  behind  in  sacs  and  pouches  at  the  time  of  operation,  and  partly 
owing  to  the  inability  to  completely  empty  the  bladder  later,  so  that 
fresh  stones  descending  from  the  kidneys  are  retained  Avhile  other 
foreign  bodies,  such  as  shreds  and  sloughs  from  an  inflamed  bladder,  may 
form  nuclei  for  the  formation  of  fresh  stones.  With  a  view  to  preventing 
recurrence  in  these  cases,  the  author  lays  great  stress  on  the  importance 
of  thorough  Avashing  out  at  the  time  of  operation,  also  once  a  week  for 
three  or  four  months  after  the  operation,  and  also  of  the  adoption  of 
measures  aiming  at  the  reduction  of  the  size  of  the  prostate. 

Operation  (Figs.  168 — 171). — The  preparatory  treatment  has  been 
much  simplified.  It  is  now  recognised  that  the  best  course  is  to  remove 
the  stone  at  once :  previous  passage  of  sounds,  and  injections  of  the 
bladder,*  are  now  but  little  used.  A  few  days'  rest,  bland,  unirri- 
tating  liquid  diet,  urotropine  if  there  is  cystitis,  mild  aperients,  and 
securing  sleep  are  the  chief  indications. 

The  instruments  required  will  be  gathered  from  the  following 
account:  The  patient  having  been  anaesthetised  and  lying  on  a  firm 
couch  or  mattress  close  to  the  right  side  of  the  bed  or  table,  with  his 
pelvis  raised,  and  the  body  and  limbs  well  protected  from  chill,  the 
surgeon,  standing  on  the  right  side  with  his  instruments  close  to  him, 
introduces  his  lithotrite.  In  doing  this  care  must  be  taken  not  to  get 
the  blades  hitched  either  just  in  front  of  the  triangular  ligament  or  in 
the  roof  of  the  prostatic  urethra.  This  will  be  secured  by  not 
depressing  the  instrument  till  very  late — in  fact,  not  till  it  is  just 
about  to  enter  the  bladder.  The  instrument,  well  warmed  and  oiled,  is 
held  at  first  horizontally  over  the  groin  or  abdomen,  the  penis  being 

*  The   amount   of    urine   to    be  lield,  in    most  cases,  has  already  been    meiltioned 
(P-  411)- 


414 


OPERATIONS  OX  THE  ABDOMEN, 


Fig.  i( 


drawn  over  it,  the  shaft  being  all  the  time  gradually  brought  into  the 
vertical  position  as  the  instrument  finds  its  way  by  its  own  weight  into 
the  bulbous,  membranous,  and  prostatic  urethra.  Now,  and  not 
before,  the  handle  is  somewhat  depressed,  and  the  instrument  glides 
quickly    into  the  cavity  of   the   bladder.      If   the  prostatic  urethra   is 

enlarged  and  lengthened,  the  surgeon 
may  think  that  he  has  reached  the 
bladder,  but  the  fact  that  the  gentlest 
lateral  movement  of  the  lithotrite  is 
interfered  with  will  show  him  his 
mistake.  Pressure  with  the  instru- 
ment is  alone  allowalile  at  the  meatus; 
some  rotation  may  be  called  for  in 
guiding  the  instrument  through  the 
triangular  ligament  or  past  an  en- 
larged prostate.  In  this  latter  case 
also  the  handles  must  be  further  de- 
pressed, and  a  finger  in  the  rectum 
may  give  help. 

When   the   lithotrite   has    entered 
the  bladder  it  should  be  allowed  to 


Lithotrity,  showing  the  position  of  tho  lithotrite  during  introduction, 
grasping  the  stone  and  crushing.     (Heath.) 


slide,  very  gently,  down  the  trigone,  being  now  held  very  lightly  so  as 
at  once  to  detect  the  site  of  the  stone,  which  it  now  often  touches,  but 
must  not  displace. 

If  the  stone  is  felt  on  one  side,  the  instrument  is  gently  turned  to  the 
opposite  one,  opened,  and  then  turned  towards  the  stone.  If  it  be  not 
felt,  the  handle  of  the  instrument  being  slightly  raised,  and  the  blades 
very  gently  depressed  and  then  opened,  the  stone  will  often  drop  into 
them. 

If  this  fail,  the  instrument  is  turned,  open,  first  obliquely,  then  more 


LITHOTRITY— LITIIOLAPAXY. 


415 


horizontally,  first  to  the  one  side,  then  to  the  other.  In  the  event  of 
the  stone  still  eluding  the  lithotrite,  which  is  most  unlikely,  it  should  be 
sought  for  with  blades  depressed.  To  effect  this,  the  blades,  closed,  are 
raised  off  the  bladder  floor  by  depression  of  the  handle,  carefully 
reversed,  and  then  depressed  again  so  as  to  sweep  lightly  over  the  floor. 
They  are  then  gently  opened  and  closed,  vertically  first  and  then 
obliquely,  so  as  to  complete  the  examination. 

During  the  above,  the  following  points  must  ever  be  borne  in  mind : 

(a)  The  handle  and  shaft  of  the  lithotrite  are  to  be  kept  as  steady  as 

possible,  so  as  not  to  jar  the  sensitive  neck  of  the  bladder  needlessly. 

(h)  All  movements  are  to  be  executed  at  or  beyond  the  centre  of  the 

vesical  cavity,  the  proper  area  of  operating,  without  hurry,  rapid  move- 

FiG.   i6g. 


This  shows  a  risk  present  in  operating  in  trabeculated  bladders.  AVliile 
the  female  blade  (L)  is  in  direct  contact  with  the  stone  (S),  the  male  (L*)  is  in 
contact  with  a  ridge  of  the  mucous  membrane  (E).  B,  Bladder.  P,  Prostate. 
(E  Harrison.) 

ment,*  or  any  other  which  partakes  of  the  nature  of  a  jerk  or  concussion 
(Sir  H.  Thompson,  he.  supra  cit.,  p.  296).  (c)  The  male  blade  is  never 
to  be  brought  into  contact  with  the  neck  of  the  bladder,  unless  this  is 
rendered  necessary  by  the  position  of  the  stone. 

The  stone  being  seized  b}^  one  of  the  above  manoeuvres,  the  button! 
moved,  and  the  screw  connected — the  screw  is  gradually  turned  at  first 
to  make  the  jaws  bite,  since  a  sharp  turn  at  this  time  may  drive  the 
stone  out  either  to  right  or  left — the  calculus  is  then  carried  to  the 
centre  of  the  cavity,  which  will  show  whether  a  fold  of  mucous 
membrane  has  been  seized  (Fig.   169).     As  the  screw  is  applied  more 


*  "  Rapid  movements  produce  currents  which  keep  the  stone  more  or  less  in  motion, 
so  that  it  is  less  easily  seized  than  when  the  surrounding  fluid  is  in  a  state  of  rest " 
(Thompson). 

t  In  this  respect  Prof.  Bigelow's  lithotrite  seems  inferior  to  Sir  H.  Thompson's,  the 
working  of  the  button  in  the  latter  being  smoother  and  less  vibrating. 


4l6  OPERATIONS   OX  THE  ABDOMEX. 

and  more  forcibly,  one  or  other  of  the  following  will  be  noticed.  If  not 
well  caught,  and  if  hard,  the  stone  will  be  pushed  out  of  the  jaws ;  if 
hard  and  well  gripped,  it  is  felt  to  split  into  fragments ;  if  soft,  and 
held,  it  crumbles  down.  If  extremely  hard,  as  a  pure  lithic  acid  or 
oxalate,  any  attempt  at  advancing  the  screw  is  met  by  this  distinctly 
recoiling  instead  of  advancing.  Each  surgeon  must  now  decide  for 
himself,  according  to  his  knowledge  of  his  instruments  and  reliance  on 
his  power  to  deal  with  large,  hard  fragments,  whether  to  continue  or  at 
once  to  perform  lithotomy.  If  he  continue,  the  resistance  will  be  felt  to 
give  wav,  in  the  case  of  a  very  hard  stone,  by  a  sudden  sharp  crack ;  in 
one  less  hard,  more  gradually.  If  the  stone  does  not  crack,  Freyer  (loc. 
supra  cit.)  advises  that  the  lithotrite  be  unscrewed,  the  stone  caught 
in  another  axis,  and  the  lithotrite  again  screwed  home.  By  repeating 
this,  if  necessary,  the  stone  will  usually  at  last  give  way.  The  same 
surgeon  also  recommends  that  in  dealing  with  stones  which  are  more  or 
less  round  and  so  large  that  the  lithotrite  will  not  lock  in  any  direction, 
the  ]'aws  of  the  instrument  should  be  dug  into  one  side  of  the  stone  and 
screwed  up,  a  portion  of  the  crust  being  thus  broken  off.  By  repeating 
this  a  number  of  times,  sufficient  reduction  in  size  will  take  place 
to  allow  of  the  lithotrite  being  locked  on  the  stone.  In  overcoming 
much  resistance  the  surgeon  either  screws  up  the  male  blade  as  hard  as 
he  can  and  keeps  it  so,  or,  having  gently  unscrewed  it  a  little,  screws  it 
up  again  with  a  series  of  light  jerks  so  as  to  communicate  blows  to  the 
stone.  Cracking  of  the  stone  having  taken  place,  the  fragments  will 
usually  fall  close  to  the  original  site.  Thus  the  lithotrite  has  only  to  be 
kept  as  immovable  as  possible  to  ensure,  on  drawing  out  and  again 
closing  the  male  blade,  the  seizure  of  a  fragment.*  This  is  crushed, 
and  the  process  repeated  again  and  again  till  sufficient  debris  is  formed. 
The  lithotrite  is  then  withdrawn  firmly  screwed  up. 

A  straight  or  curved  evacuating  tube,  No.  i6  for  a  stone  of  moderate 
size,  and  i8  for  a  large  one,  is  then  introduced,  the  evacuator,  filled  with 
a  warm  solution  of  boracic  acid  or  dilute  Thompson's  fluid  (p.  402),  is 
connected,  the  meatus  being  first  incised  with  a  narrow  probe-pointed 
bistoury  downwards  by  the  side  of  the  frgenum,  if  needful.  The  tube, 
if  curved,  should  be  held  downwards  at  first,  but  not  quite  on  the 
bladder  floor;  then  to  one  side  or  the  other;  then  upwards,  washings 
being  cariied  on  at  the  time  that  these  movements  are  made.  A  straight 
tube  should  lie  with  its  orifice  just  Avithin  the  neck  of  the  bladder. 
Dr.  Keyes  {Intern.  Encycl.  of  Surg.,  vol.  vi.  p.  244)  gives  this  pr-e- 
caution  as  to  getting  rid  of  air  entirely :  "  The  urine,  having  trickled 
away  through  the  tube,  leaves  the  latter  full  of  air,  an  element  fatal  to 
nicet}'  of  washing.  This  air  may  be  disposed  of  most  simply.  The  tube 
■  is  withdrawn  until  its  eye  is  in  the  prostatic  sinus,  the  Avashing-bottle 
is  attached,  and  the  stop-cock  turned,  but  no  further  suction  made.  In 
an  instant,  the  air  contained  in  the  tube  is  heard  ascending  through  the 
stop-cock  and  mounting  into  the  top  of  the  evacuator,  where  it  does  no 
harm,  and  whence  it  cannot  possibly  return  into  the  bladder."  While 
his  left  hand  supports  the  evacuator,  with  his  right  the  surgeon  gently 
l)ut  quickly  squeezes  the  bag  with  sufficient  force  to  send  in  about  two 

*  It  is  not  always  easj^  to  distinguish  between  a  piece  of  soft  stone  enveloj^ed  in 
inspissated  mucus  and  the  lining  membrane  of  the  bladder. 


LITIIOTIilTY— LlTIIiJLAPAXY, 


417 


ounces  of  fluid.  On  relaxing  the  pressure  an  outward  current  takes  place, 
bringing  with  it  crushed  fragments.  Sir  H.  Thompson  recommends 
that,  after  the  bag  has  expanded  and  the  current  apparently  ceased, 
the  surgeon  should  wait  a  few  seconds,  "as  at  that  precise  time  it  is 
quite  common  for  one  or  two  of  the  larger  fragments  to  drop  into  the 
receiver  which  would  have  been  driven  back,  perhaps,  by  too  rapidly 
resuming  the  pressure." 

If,  after  several  washings,  the  outflow  stops,  and  the  bag  no  longer 

Fig.  170. 


Sir  H.  Thompson's  aspirator,  last  jiatteru  but  one.     (Freyer.)* 

expands,  the  end  of  the  evacuator  is  blocked  either  by  a  fragment  of 
stone,  or  a  small  calculus,  a  clot  of  blood,  or  the  mucous  membrane  of 
the  bladder.  If  it  be  a  fragment,  as  is  usually  the  case,  or  a  clot, 
dislodgment  may  be  efiected  b}'  sending  in  quickly  a  gush  of  fluid,  or 
by  the  use  of  a  gum-elastic  stylet,  after  unscrewing  the  tube.  Impact 
of  the  bladder  generally  takes  place  when  a  curved  evacuator  is  tiu-ned 


*  Of  this  instrument  Dr.  Frcj-cr  writes  (^Litholapa-ry.  p.  25)  :  ••  I  must  confess  a  great 
liking  for  Thompson's  instrument.  One  of  this  variety  made  for  me  by  Messrs.  Weiss 
I  have  worked  with  for  four  years,  and  though  it  has  assisted  at  130  operations,  and 
been  through  three  hot  weathers  in  the  plains  of  India,  it  is  still  as  efficient  as  much 
newer  instruments  I  possess,  a  fact  which  speaks  well  for  the  india-rubber  employed  in 
its  construction." 

VOL.  II.  27 


4i8 


OPERATIONS  ON  THE  ABDOMEN. 


upwards,  and  when  the  bLadder  is  empty.  The  sensation  given  may  be 
a  kind  of  flap,  simulating  the  click  of  a  fragment ;  more  often  it  is  a 
dull,  vibrating  thud,  easily  recognised.  More  fluid  must  be  at  once 
injected. 

If  a  large  fragment  is  felt  striking  against  the  tube,  or  if  the  surgeon 
is  certain  that  several  good-sized  fragments  remain,  he  removes  the 
tube  and  evacuator,  and,  while  an  assistant  withdraws  the  blood-stained 
fluid  and  fragments,  and  recharges  the  evacuator,  he  introduces  a  small 


Fig.  171.* 


Tho  operator  is  here  supposed  to  be  sitting  between  the  thighs 
of  the  patient.  The  expansion  of  the  compressed  bulb  will  aspiiate 
a  part  of  the  abundant  debris  suspended  in  the  fluid.  The  frag- 
ments, being  too  abundant,  have  been  dispersed.     (Bigelow.) 

lithotrite  and  crushes  up  suflficient  debris  to  go  on  again  with  the 
washings. 

All  the  time  the  surgeon  must  keep  before  his  eyes  a  mental  picture 
of  the  interior  of  the  bladder,  perhaps  diseased,  the  ureters,  perhaps 
dilated,  leading  up  to  kidne}^  pelves  enlarged,  and  remember  that  the 
effects  of  an}^  squeeze  of  his  hands  are  felt,  not  only  all  over  the  bladder, 
but  perhaps  in  the  ureters  and  kidneys  as  well. 

Detection  and  Seizure  of  the  Last  Fragment. — This  is,  as  is  well 
known,  a  matter  of  much  difiiculty,  owing  to  the  facility  with  which 
small  fragments  get  hidden  in  some  folds  of  mucous  membrane  or 
enveloped  in  blood-clot.  As  long  as  there  is  any  "  clicking  "  against 
the  tube,  the  surgeon  must  persevere  in  his  attempts  at  complete  re- 
moval. If,  after  several  washings,  nothing  comes  out  into  the  receiver, 
the  surgeon  should  listen  carefully  over  the  bladder,  as  thus  advised  by 

*  The  above  evacuator  is  now  old-fashioned.  Mr.  Gokling  Bird's  pattern,  or  tho 
one  figured  at  p.  417,  will  be  found  the  most  handy. 


LITIIOTRITY — LITHOLAPAXY.  419 

Dr.  Keyes  :  *  "  The  tube  is  turned  in  various  positions,  and  the  operator 
listens.  The  swash  of  the  water  as  it  rushes  in  and  out  is  heard  with 
startling-  distinctness,  and,  if  the  management  of  the  tube  is  skilful,  any 
fragment  of  stone  lying  loose  in  the  bladder  is  sure  in  a  short  time  to 
be  driven  against  the  metallic  tube  so  as  to  announce  its  presence  by 
a  characteristic  click,  quite  distinct  from  that  emitted  by  the  flapping 
of  the  bladder  wall  against  the  eye  of  the  instrument.  Fine  sand  and 
thin  scales  of  stone  make  no  sharp  click,  and  all  such  may  be  left  to 
pass  by  Nature's  efforts,  but  any  piece  large  enough  to  require  the 
lithotrite  can  hardly  escape  detection  by  the  educated  ear." 

I'ime  occiqned  in  Litholapaxy. — This  may  be,  on  an  average,  from 
half  an  hour  to  an  hour  and  a  half.  Prof.  Bigelow  (Amer.  Journ.  Med. 
Sci.,  Jan.  1878)  operated  continuously  for  upwards  of  three  hours, 
removing  744  grains,  the  patient  making  a  good  recovery.  Mr.  R. 
Harrison  (Brit.  Med.  Journ.,  Aug.  10,  1882)  removed  a  two  and  a  half 
ounce  stone  in  two  hours  and  ten  minutes  (ride  also  p.  409). 

The  Old  and  the  New  Operation  of  Lithotrity  briefly  contrasted. — 
Old  lithotrity  advocated  short  sittings,  and  brief  use  of  instruments, 
and  left  the  expulsion  of  fragments,  &c.,  as  much  as  possible  to  Nature. 
It  probably  requires  less  skill,  and,  in  Mr.  Cadge's  words,  "  is  gentler, 
milder,  less  formidable  altogether ;  no  anaesthetic  is  probably  required  ; 

no  extra  assistance A  nervous,  timid  patient  may  prefer  this  to 

the  more  heroic  and  rougher,  if  more  expeditious,  method."  It  might 
be  added  that  it  is  less  tiring  to  the  surgeon.  But  these  advantages 
are  trifling  as  compared  with  its  disadvantages,  which  are  done  away 
with  by  the  new  operation,  of  which  the  chief  are  the  prolonged  passage 
of  fragments,  often  rough  and  angular,  along  a  bruised  urethra.  Mr. 
Milton  (lor.  supra  cit.)  has  invented  an  evacuating  lithotrite — a  com- 
bination of  the  usual  crushing  and  evacuating  instruments,  which  will 
be  useful  in  the  aged,  with  a  moderate  sized  and  soft  stone  and  enlarged 
prostate,  from  the  single  introduction  required. 

The  new  method  of  litholapaxy,  introduced  by  Prof.  Bigelow,  resulted 
from,  and  was  led  up  to  by,  several  achievements  of  modern  surgery. 
Without  anaesthetics,  without  the  knowledge  of  the  large  instruments 
admitted  hy  the  urethra,  without  the  pitch  of  perfection  and  power  to 
which  modern  instruments  have  been  brought,  litholapaxy  would  still 
be  an  impossibility.  Owing  to  its  brilliant  success,  and  the  rapidity 
with  which  it  relieves  the  patient,  the  single-sitting  method  has 
practically  rendered  the  other  obsolete. 

After-treatment. — The  chief  points  here  are  :  rest  in  bed,  the  patient 
turning  on  his  side  to  pass  water,  for  the  first  few  days  ;  hot  fomenta- 
tions to  the  abdomen,  and  hot  bottles  at  first ;  morphia  subcutaneously, 
if  indicated ;  warm  milk,  barley-water,  mineral  waters  or  lemonade,  a 
little  whisky  or  brand v  being  given,  if  needful ;  all  chills  should  be 
carefully  avoided.  M^-.  Milton  (loc.  supra  cif.)  recommends  salicylate 
of  soda  at  first  every  two  and  then  every  four  hours  if  there  is  fever, 
and  diuretin  if  there  is  diminution  of  urine.  In  each  case  the  amount 
given  is  one  gramme.  If  cystitis  is  present,  urotropine  in  doses  of 
5  to   10  grs.  thrice  daily  should  be  given. 


*  Loc.  siqtra  cit.,  p.  246.     The  whole  of  this  account,  with   its   vigorous   life-like 
language,  will  well  repay  perusal. 


420  OPERATIONS  ON  THE  ABDOMEN. 

in  addition  to  the  above,  the  putting  the  patient  frequently  in  ho'j 
hip-baths  for  a  quarter  of  an  hour,  the  occasional  passage  of  a  soft 
catheter,  and  the  rendering  the  urine  alkaline,  will  give  much  relief. 
The  urine  should  always  be  strained  through  muslin  to  collect  the 
debris. 

It  is  advisable  also  to  once  more  thoroughly  wash  out  the  bladder 
with  the  evacuator  a  week  after  the  operation,  as  a  safeguard  against 
recurrence  from  small  fragments  left  behind  at  the  time  of  operation. 
Where  there  is  any  obstruction,  such  as  an  enlarged  prostate,  Mr. 
Harrison  recommends  frequent  washings  over  a  prolonged  period  (vide 
Siqrrri,  p.  413). 

Complications  diiring  Lithotrity  and  Litholapaxy. 

I .  Escape  of  Urine. — This  may  take  place  during  or  after  the  passage 
of  the  lithotrite.  The  penis  should  be  compressed  against  the  lithotrite, 
and  a  pause  made  while  the  patient  is  got  more  full}'  under  the  anaes- 
thetic. If  this  fail,  tying  a  tape  round  the  penis  and  instrument, 
injecting  a  little  fluid,  or  j^utting  off  the  operation  till  the  bladder  is 
in  a  more  fitting  state  after  the  use  of  instruments,  injections,  and 
such  drugs  as  belladonna  and  subcutaneous  injections  of  morphia,  maj' 
be  made  use  of.  2.  Haemorrhage. — Sufficient  blood  to  stain  the  fluid  in 
the  evacuator  during  the  operation,  and  the  urine  for  a  day  or  two  after 
it,  is  not  uncommon.  If  the  haemorrhage  during  the  operation  is  severe, 
the  surgeon  must  decide  whether  it  is  due  to  the  damage  to  the  bladder 
or  urethra,  to  his  having  scratched  the  latter  by  withdrawing  a  frag- 
ment in  the  evacuator"s  eye.  to  bi'uising  of  an  enlarged  prostate,  or  to 
co-existent  growth.  In  this  last  case  the  supra-pubic  operation  will 
probably  have  to  be  performed  either  at  the  time  or  later ;  in  the  other 
cases  the  surgeon  must  decide  on  completing  or  deferring  the  crushing' 
by  the  amount  he  has  already  effected,  his  experience,  and  the  amount 
of  the  bruising  inflicted.  3.  Clogging  or  Fracture  of  the  Lithotrite. — 
Clogging  or  impaction  is  liable  to  happen  with  a  non-fenestrated  instru- 
ment with  weak  and  narrow  blades.  With  one  properly  made,  with  a& 
broad  blades  as  possible,  and  the  male  one  blunt,  roughened,  and 
laterally  bevelled  ofi*.  the  accident  is  unlikely.  When  it  occurs,  it  must 
be  met  by  percussing  the  instrument,  if  opening  and  closing  the  blades, 
and  thus  freeing  them  in  the  fluid,  is  impossible.  If  the  impaction 
persist,  the  blades  must  be  withdrawn  as  far  as  possible  by  safely 
maintained  traction.  If  no  force  that  is  wise  will  withdraw  them,  they 
should  be  cut  upon  in  the  perinseum,  thrust ,  out,  unloaded,  and 
■\Wthdrawn,  and  the  rest  of  the  stone  removed  as  by  a  median  lithotomy. 
If.  owing  to  any  defect  in  the  instrument,  the  blades,  though  not 
clogged,  cannot  be  screwed  up.  they  must  be  cut  upon  as  above,  thrust 
through,  and.  if  possible,  filed  off.  If  a  blade  break  off",  it  must  either 
be  caught  and  withdrawn  by  another  lithotrite.  or  the  patient  cut  at 
once.     4.  Injury  to  the  Bladder  or  Urethra. 

Complications  after  Litholapaxy  and  Lithotrity. — These  are  much 
the  same  as  those  already  given  at  p.  408.  as  occurring  after  lithotoni}'. 
The  chief  differences  are  the  greater  liability  to  rigors  and  urinarj'  fever, 
and  the  greater  frequency  of  epididyniitis.  Bruising  of  the  urethra  has 
also  to  be  remembered,  whether  by  the  instruments,  or,  after  the  old- 
fashioned  lithotrit}',  by  the  passage  of  fragments. 


LITHOLAPAXY  IN  MALE  CIIILDREX.  42 1 

PERINEAL  LITHOTRITY. 

This  operation — first  suggested  and  carried  out  by  Dolbeau — consists 
essentially  of  lithotrity  carried  out  through  a  small  median  or  lateral 
perinatal  incision. 

Surgeon-Major  Keegan  (Brit.  Med.  Journ.,  vol.  ii.  1897,  p.  23)  observes 
"that  experience  has  taught  that  supra-pubic  lithotomy  has  not  fulfilled 
the  early  promise  of  the  days  of  its  revival,  for  the  mortalit}'  which  has 
followed  it  in  cases  of  very  large  calculi  occurring  among  males  at  the 
middle  period  of  life  is  very  considerable.  There  is,  therefore,  a  growing 
consensus  of  opinion  among  surgeons  practising  in  the  East,  where 
cases  of  very  large  calculi  are  of  frequent  occurrence,  that  perinteal 
lithotrity,  whether  median  or  lateral,  will  in  the  near  future  supersede 
supra-pubic  lithotomy  in  dealing  with  this  very  important  class  of 
cases  of  stone  in  the  bladder."  Keginald  Harrison  (Brit.  Med.  Journ., 
Dec.  12.  1896)  also  recommends  the  operation,  having  performed  it 
fifteen  times  without  a  death  or  recurrence.  In  one  case  a  very  hard 
urate  stone,  \\eighing  over  three  ounces,  was  crushed  and  removed  in 
about  five  minutes,  an  enlarged  middle  lobe  of  the  prostate  being- 
removed  at  the  same  time. 

Some  of  the  chief  points  claimed  in  favour  of  this  operation  are : 
(i)  Large  stones  may  be  crushed  in  a  short  space  of  time.  (2)  An 
enlarged  prostate  may  be  dealt  with  at  the  same  time.  (3)  It  may 
be  performed  in  cases  of  stricture  or  enlarged  prostate.  (4)  It  is  less 
severe  than  the  supra-pubic  operation.  (5)  Excellent  drainage  is 
provided  in  cases  of  cystitis,  &c.  (6)  Digital  examination  can  be  made 
use  of  to  determine  Avhether  all  the  fragments  have  been  removed. 

Before  it  can  be  decided,  however,  whether  this  operation  should 
entirely  supersede  the  supra-pubic  operation,  further  experience  mvist 
be  awaited,  particularly  with  regard  to  the  important  cpiestion  of 
recurrence. 

Operation. — A  small  median  or  lateral  perinatal  incision  is  made  on  a 
grooved  stafi",  as  in  lithotomy,  sufiiciently  large  for  the  introduction  of 
the  finger  into  the  bladder  for  the  purposes  of  examination.  The 
"giant"  lithotrite  specially  devised  by  Mr.  Keegan  (loc.  siqrra  cit.)  is 
then  introduced  into  the  bladder  and  the  stone  crushed  as  in  ordinary 
lithotrity.  The  fragments  may  be  removed  either  by  means  of  forceps 
or  an  aspirator  connected  Avith  a  specially  large  evacuating  cannida. 
A  tube  is  then  introduced  into  the  bladder  through  the  wound  for 
purposes  of  drainage. 

Mr.  Keegan  says  that  the  specially  strong  "  giant "  lithotrite  devised 
by  him,  which  is  of  the  size  of  a  No.  20  catheter  in  the  stem  and  of 
No.  25y  at  the  angle.  "  will  readily  break  up  a  hard  calculus  weighing 
six  to  eisht  ounces." 


LITHOLAPAXY  IN   MALE   CHILDREN. 

The  advisability  of  this  mode  of  treating  stone  has  been  strongly 
advocated  by  Surgeon-Major  Keegan,*  who,  after  a  wide  experience  of 

*  Lithola2)axy  in  Male  Children  and  Male  Adults  (Churchill,  1887);  Lancet,  1886. 


422  OPEEATIONS  ON  THE  ABDOMEN. 

large  stones  in  India,  is  inclined  to  think  that  the  objections  nsnally 
made  to  litholapaxy  in  boys  are  not  valid.  Thus  :  (i)  as  to  the  small- 
ness  of  the  bladder,  the  bladder  of  a  boy  of  even  only  three  or  four  is,  as 
a  rule,  quite  roomy  enough  to  permit  of  the  efficient  working  of  a  small 
lithotrite  and  a  medium  or  full-sized  aspirator  if  gently  worked.  The 
bladders  of  boys  with  stones  are,  as  a  rule,  healthy,  and  will  stand  more 
distension  proportionately  to  their  capacity  than  the  bladders  of  old 
men.  (2)  The  extreme  sensitivenes.'^  of  the  mucous  membrane  of  the 
bladder  aiul  urethra.  Mr.  Keegan  thinks  that,  with  an  anassthetic,  this 
ma}'  be  safely  disregarded.  (3)  The  liability  to  laceration  of  the  mucous 
membrane  of  the  bladder  and  urethra.  This  objection  is,  he  thinks, 
a  theoretical  one  only.  (4)  The  small  calibre  of  the  urethra.  Mr. 
Keegan  states  that  not  only  is  the  calibre  of  the  urethra  in  boys  of  six 
or  eight  not  very  small,  but  that  of  boys  of  only  three  or  four  is  some- 
times very  large.  As  in  men,  the  true  calibre  of  the  urethra  cannot  be 
told  unless  the  meatus,  which  is  sometimes  very  small,  is  incised. 
Speaking  generally,  the  urethra  of  a  l3oy  from  three  to  six  will  admit  a 
No.  7  or  a  No.  8  lithotrite  (Eng.  scale),  and  that  of  a  boy  of  eight  or  ten 
will  admit  a  No.  10,  a  No.  1 1.  and  even  sometimes  a  No.  14.  "  With  a 
No.  8  lithotrite  and  a  No.  8  evacuating  catheter  it  is,  I  find,  quite 
feasible  to  dispose  of  a  mulberry  calculus  weighing  between  two  and 
three  hundred  grains  in  an  hour's  time."' 

In  a  recent  publication  {Ind.  Med..  Gaz.,  Aug.  1900)  Mr.  Keegan 
gives  the  results  of  a  series  of  500  litholapaxies  in  boys.  He  says  : 
"  Grouping  the  500  litholapaxies  together,  the  work  mainh'  of  three 
surgeons,  I  find  that  the  average  age  of  the  boys  operated  on  was  six 
years,  the  average  weight  of  stone  removed  at  each  operation  was 
ninety-five  grains,  and  the  stay  in  hospital  after  operation  amounted 
to  four  days.  The  mortality,  as  already  stated,  was  41.  or  2*2  per 
cent."  Of  the  500  operations,  Mr.  Keegan  did  239,  and  lost  5  cases, 
the  cause  of  death  being  extensive  kidney  disease.  Mr.  Keegan  had 
constructed  by  Messrs.  AVeiss  a  No.  3|  lithotrite,  which  has  done  very 
good  work,  and  advises  anyone  wishing  to  give  litholapaxy  in  boys 
a  fair  trial  to  pro^nde  himself  with  a  set  of  completely  fenestrated 
lithotrites  running  from  No.  4  to  No.  lO  (Eng.  scale). 

Mr.  Keegan  insists  upon  the  completely  fenestrated  lithotrite  as  being 
the  only  perfectly  safe  instrument  to  use.  as,  ^^■ith  any  other,  clogging 
of  the  blades  is  a  vevj  likely  and  a  most  dangerous  complication. 

In  discussing,  in  the  first  edition  of  this  book,  the  advisability  of 
surgeons  adopting,  as  a  general  rule,  this  method  of  dealing  with  stone 
in  male  children,  I  pointed  out  (i)  that  one  very  important  matter,  the 
percentage  of  recurrence  after  litholapaxy  at  this  age,  had  been  left 
undealt  with  by  Mr.  Keegan ;  and  (2)  that  such  an  individual  experience, 
splendid  as  it  is,  can  scarcely  be  taken  to  furnish  a  rule  to  those 
who  onl}^  meet  with  stone  at  comparatively  rare  intervals.  Mr.  Keegan 
has  since  written  on  both  these  points  {Ind.  Med.  Gazette,  Feb.  1890, 
p.  40).  It  will  be  seen  that,  with  regard  to  the  first  point,  the  fact 
that  recurrence  after  litholapaxy  in  boys  in  India  is  so  very  small, 
is  due  to  the  opportunities  and  experience,  absolutely  unrivalled  and 
never  to  be  known  in  this  country,  which  fall  to  the  lot  of  surgeons 
in  India  in  treating  stone  in  the  bladder.  With  regard  to  my  second 
point,   that  such  an   individual   experience,   so   different  to  anj^thing 


STOXE  IX  THE  BLADDER  IX  THE  FEMALE.  423 

that  we  meet  with  here,  should  not  mislead  those  who  only  meet 
with  stone  at  comparatively  rare  intervals  to  substitute  litholapaxy 
for  the  eminently  safe  operation*  which  lateral  lithotomy  has  been 
proved  to  be  in  boys,  Mr.  Keegan,  writing  as  follows,  confirms  my 
opinion :  "I  am  disposed  to  agTee  with  Mr.  Jacobson  in  doubting  if 
in  Great  Britain  lithotomy  in  male  children  will  be  replaced  by  litho- 
lapaxy. And  why  ?  Because  to  render  himself  familiar  ^^■ith  the  use 
of  the  lithotrite,  the  surgeon  must  be  afforded  frequent  opportunities 
of  dealing  with  cases  of  stone ;  and  as  such  opportunities  occur  only 
at  rare  intervals  to  the  majority  of  hospital  surgeons  in  Great  Britain, 
they  will  therefore  very  naturally  cling  to  that  operation  which  is 
performed  by  aid  of  the  instrument  with  which  they  are  most  familiar, 
the  scalpel."" 

Owing  to  the  increasing  rareness  of  calculus  in  children  at  the  present 
time,  and  the  fact  that,  as  a  rule,  isolated  cases — and  only  successful 
ones — are  alone  published,  it  is  very  difficult  to  speak  definitely  about 
the  results  of  litholapaxy  in  children  in  European  surgery.  I  would 
call  the  attention  of  my  readers  to  a  paper  by  Alexandrow  (Bent.  Zeit. 
f.  Chir.,  1 89 1,  Bd.  xxxii.  Hft.  5,  S.  6).  This  surgeon  performed  litho- 
trity  thirty-two  times  in  boys  between  i  and  14  years  of  age  in  a 
children's  hospital  at  Moscow.  In  twenty-seven  the  operation  was 
successful ;  the  remainder  were  fatal,  and  in  three  death  occurred  from 
injury  to  the  urethra  during  the  operation.  Mr.  E.  Owen,  with  praise- 
worthy candour,  brought  a  case  before  the  Medical  Society  (Lcncet,  vol.  i. 
1 89 1,  p.  665)  in  which  fatal  rupture  of  the  bladder  had  taken  place 
during  litholapaxy  in  a  boy  aged  4. 


TREATMENT    OF    STONE    IN    THE    BLADDER    IN    THE 

FEMALE. 

Practical  Points. — The  absence  of  any  prostate  or  of  a  fixed  smooth 
trigone-surface  is  of  importance  here,  especially  with  regard  to  lithotrity. 
The  aid  given  by  a  finger  in  the  vagina,  the  dilatability  of  the  urethra, 
the  association  of  calculi  with  foreign  bodies,  are  also  well  kno\\'n.  It 
is  only  occasionally  that  enlargement  of  the  uterus  or  prolapse  of  the 
vaginal  wall  of  the  bladder  interferes  with  the  treatment  of  stone. 

Operations. 

A.  ///.  Adiilf^. — We  have  here  the  following  three  methods  to  consider : 

I.  Dilatation. — When  the  stone  is  small — i.e.,  the  size  of  a  filbert,  a 
stone  not  exceeding  three-quarters  of  an  inch  in  its  largest  diameter — it 
may  be  safely  removed  by  rapid  dilatation  with  Hegar's  dilators, 
followed  by  a  finger  (the  little  one  first). 

It  is  not  meant  by  this  that  much  larger  stones  have  not  been  success- 
fully passed  and  removed  from  the  female  bladder.  Thus,  Dr.  Yelloly 
(Med.-Chir.  Trans.,  vol.  vi.  p.  574)   gives   a   case   in   which   a   stone, 

*  Mr.  Bryant,  in  writing  of  the  successes  which  lateral  lithotomy  has  given  in 
children  (^Suryery,  vol.  ii.  p.  106)  states  that  during  seventeen  years  100  patients  had 
been  cut  consecutively  at  Guy's  without  a  death.  Another  matter  deserves  mention. 
Cutting  for  stone  is  no  longer  limited,  as  of  old,  to  a  few  great  centres.  How  many 
institutions  in  or  out  of  London,  how  many  cottage  hospitals,  will  be  provided  with 
the  set  of  special  instruments  which  are  necessary .' 


424  .  OPERATIONS  ON  THE  ABDOMEN. 

weighing  3  oz.  3^  clrs.,  was  extracted :  incontinence  followed.  Where 
large  calculi — e.g.,  of  6  oz. — have  come  away  spontaneousl}',  it  has  been 
usually  b}"  a  process  of  prolapsus  and  ulceration  combined.  We  do  not 
yet  know  what  is  the  greatest  dilatation  which  the  female  urethra  will 
safelj^  bear.  Perhaps  the  limit  given  above  is,  if  anything,  too  small. 
Erichsen  [Swgeri/,  vol.  ii.  p.  1024)  gives  "  8  or  10  lines  in  diameter" 
as  the  size  of  a  stone  which  can  be  safely  extracted  by  this  means.  Sir 
H.  Thompson  (Sj/st.  of  Sur<j.,  vol.  iii.  p.  308)  says,  '"dilatation  should 
never  be  employed  for  any  calculus  larger  than  a  small  nut  or  a  large 
bean  in  an  adult,  which  limits  its  application  to  very  few  cases."  Mr. 
Bryant (/S'wr^e'n/,  vol.  ii.  p.  120)  states  that,  ''in  children,  a  stone  three- 
quarters  of  an  inch  in  diameter,  and  in  adults  one  inch,  may  be  fearlessly 
removed  from  the  bladder  by  ra})id  dilatation  and  extraction,  with  the 
patient  under  the  influence  of  chloroform.  I  have  removed  larger 
calculi,  two  inches  in  diameter,  by  this  means,  without  an}^  injurious 
after-effect,  but  it  is  probably  not  wise  to  make  the  attempt,  the  surgeon 
j^ossessing  in  lithotrity  an  efficient  aid  or  substitute."  Dr.  Keyes  (Intern. 
Encycl.  of  Surg.,  vol.  vi.  p.  297)  recommends  not  dilating  the  urethra 
more  than  three-quarters  of  an  inch. 

2.  Litholapaxy. — By  this  means  calculus  in  the  female  bladder  may 
be  most  frequently  and  efficiently  treated.  Thus,  hard  stones  under  an 
ounce,  and  phosphatic  ones  of  a  much  larger  size,  niaj"  be  dealt  with  at 
one  sitting.  The  character  of  the  ring  or  sound  with  the  staff,  the  bite 
of  the  lithotrite,  and  the  condition  of  the  urine  will  aid  here.  A  shorter 
instrument  will  be  found  much  more  convenient  to  work  with.  Where 
there  is  much  irritability  of  the  bladder,  much  difficult}"  will  be  met 
with  in  keeping  fluid  in  it,  owing  to  the  absence  of  a  prostate  and  the 
shortness  and  directness  of  the  urethra.  The  pelvis  must  be  well  elevated, , 
the  patient  placed  fully  under  the  anaesthetic,  and  the  finger  of  an  assist- 
ant should  make  pressure  on  the  urethra.  In  other  respects  the  operation 
resembles  that  already  fully  given  for  the  male  (p.  413).  The  dilatable 
urethra  admits  a  full-size  evacuating  tube. 

3.  Lithotomy. — This  operation  is  called  for  Avhen  the  stones  are 
multiple,*  when  one  is  large,  especially  if  mainly  hard  as  well,  when 
there  is  a  foreign  body  as  a  nucleus, t  when  there  is  great  irritability 
with  ulceration  of  the  bladder,  or  when  a  growth  co-exists. 

Of  the  following  methods — [a)  vaginal,  (h)  supra-j^ubic,  (c)  m-ethral, 
and  (d)  the  lateral  method  of  Buchanan — the  first  two  only  need  be 
alluded  to. 

Vaginal  LWiotomi/. — By  this  is  meant  extraction  of  a  stone  through 


*  As  ill  Dr.  (falabiii's  case  (^Ohaf.  Soc.  Tran.s.,  April  7.  1880).  in  which  twelve  lars^e 
calculi  and  about  fifty  smaller  ones  were  removed  successfully  by  vaginal  lithotomy 
from  the  bladder  of  a  woman  aged  61. 

f  As  in  the  large  stone  formed  round  a  hair-pin,  and  figured  (p.  579)  by  Hart  and 
Barbour  in  their  Mamtal  of  Gynfecology.  Here  the  projection  of  the  hair-pin  on  either 
side  of  the  stone  would  indicate,  nowadays,  the  supra-pubic  operation.  I  have  alluded 
to  a  similar  case  in  my  practice  at  p.  406.  Some  of  my  readers  may  remember  that  a  few 
years  ago  an  inquest  was  held  in  London  on  the  body  of  a  girl  who  died  with  an  un- 
detected calculus  in  the  bladder,  which  dated  to  a  hair-pin.  The  sarcastic  remarks  of 
the  coroner  led  to  some  correspondence  in  the  papers,  from  which  it  would  appear  that 
these  calculi  are  less  rare  than  has  been  believed. 


STONE  IN  THE  BLADDER  IX  THE  FEMALE.        425 

an  incision  in  the  anterior  vaginal  wall,  behind  the  vesical  orifice  of  the 
urethra,  and  thus  not  interfering  with  this  canal  at  all. 

This  anterior  Avail  is  aboujfc  four  inches  long  in  the  adult ;  in  relation 
with  it  anteriorly  is  the  urethra,  to  be  felt  as  a  cord  through  this  wall, 
behind  this  the  bladder,  and  farther  back  the  os  and  cervix  uteri.  No 
peritoneum  is  normally  in  relation  with  this  wall,  as  this  membrane 
leaves  the  uterus  half-way  down  to  pass  directly  on  to  the  bladder.  No 
important  A'essels  or  nerves  are  met  with  in  vaginal  lithotomy  ;  but  this, 
though  the  simplest  and  easiest  of  all  the  methods  of  cutting  for  stone, 
Avill  be  but  rarely  called  for.  as  in  all  moderate  stones  in  women, 
litholapaxy  is  usually  available,  while  in  the  case  of  larger  ones,  and 
with  all  calculi  in  female  children,  the  supra-pubic  method  is  indicated, 
save  for  tiny  stones  which  can  be  removed  after  dilatation.  The  only 
drawback  of  a  vaginal  lithotomy  in  women  is  the  risk  of  a  fistula,  but 
this  need  only  be  taken  into  account  where  phosphatic  urine  is  present, 
or  where  the  edges  of  the  wound  have  been  bruised  during  the  extraction 
of  the  stone.  In  either  case  the  calculus  will  probably  be  a  large  one  or 
multiple,  a  condition,  as  already  stated,  which  is  better  dealt  with  other- 
Avise.  The  following  case,  which  came  under  my  care  in  1889,  is  a  good 
instance  of  how  the  operation  may  be  occasionally  called  for : 

"  Vaginal  Lithotomy  in  a  Patient  Six  Months  and  a  Half  Pregnant  ;  Immediate 
Suture  of  the  Wound— Eecovery  ;  Normal  Delivery  at  Full  Time  "  ^Lancet,  vol.  i.  1889, 
p.  628).  A.  L..  aged  27,  was  sent  to  me  by  Dr.  Montagu  Day,  of  Harlow.  December  7, 
1888.  For  three  years  she  had  had  bladtler  trouble— viz.,  hypogastric  pain,  cystitis, 
very  frequent  micturition  day  and  night,  with  stoppaiges  of  the  stream,  and  acute 
suffering  after  the  bladder  was  emptied.  The  patient  was  extremely  timid  and  nervous, 
owing  to  her  four  confinements  having  been  "  tight  "  and  lingering.  Craniotomy  had 
been  required  with  the  first,  and,  with  another,  labour  was  induced  at  seven  months. — 
December  8.  The  urethra  was  dilated,  and  the  bladder  explored.  A  calculus,  appa- 
rently an  inch  in  either  diameter,  was  felt ;  the  bladder  was  extremely  contracted 
with  its  mucous  membrane  in  places  raw  and  bleeding,  in  others  encrusted  with 
phosphates.  It  was  decided,  for  the  reasons  given  below  (426),  to  perform  vaginal 
lithotomy. — December  10.  Twenty-four  hours  after  the  exploration  the  patient  had 
recovered  control  over  her  bladder.  The  vagina  was  thoroughly  syringed  out  with 
hydr.  perch,  (i  to  1000).  the  posterior  wall  was  well  drawn  down  with  a  duckbiU 
speculum.  A  straight  lithotomy  staff  (No.  4)  was  then  passed,  and  the  site  of  the 
stone  determined.  A  sharp  hook  was  next  inserted  into  the  posterior  part  of  the 
urethra  so  as  to  drag  the  anterior  wall  of  the  vagina  upwards  and  forwards.  This, 
however,  caused  such  free  oozing  that  it  had  to  be  removed,  and  sponge-pressure 
applied.  The  bleeding  was  partly  caused  by  the  vascularity  of  the  parts  due  to 
pregnancy,  and  partly  by  that  set  up  by  the  dilatation  of  the  urethra  two  days  before. 
A  sharp-pointed  bistoury,  introduced  so  as  to  avoid  the  urethra  and  neck  of  the 
bladder,  was  carried  into  the  groove  of  the  staff  through  the  anterior  wall  of  the 
vagina  and  fundus  of  the  bladder,  and  then  backwards  for  nearly  two  inches.  The 
gush  of  urine  which  at  once  followed  on  the  withdrawal  of  the  knife  carried  the  stone 
downwards,  and  it  was  extracted  with  lithotomy  forceps  with  the  utmost  ease.  After 
the  bladder  had  been  explored  with  the  finger,  it  was  repeatedly  washed  out  from  the 
wound*  with  diluted  Thompson's  fluid.  Little  bleeding  had  followed  on  the  incision, 
antl  it  was  clear  that  sutures  would  entirely  control  what  remained.  The  vagina  having 
been  well  sponged  out.  the  edges  of  the  incision,  clean  cut  and  without  bruising.-|-  were 
adjusted  with  six  salmon-gut  sutures  and  four  of  horse-hair.      The  apposition  was 

*  It  would  be  wiser  to  do  this  from  the  urethra. 

t  Under  less  favourable  conditions  closing  the  wound  may  have  to  be  deferred  till 
he  parts  arc  quite  healthy. 


426  OPEEATIOXS  ON  THE  ABDOMEN. 

tested  with  a  fine  probe,  especially  behind,  where  a  little  difficulty  was  met  with 
in  inserting  the  sutures.  Owing  to  the  patient's  straining  at  this  time,  some  urine 
escaped  from  the  urethra,  but  none  came  through  the  wound.  The  vagina  was  next 
thoroughly  syringed  with  a  solution  of  hydr.  perch,  (i  in  3000),  dried  out  with 
aseptic  sponges,  and  dusted  with  iodoform.  To  secure  more  certain  asepsis,  and  also 
to  support  the  wound  and  sutures,  the  vagina  was  lightly  plugged  with  strips  of 
iodoform  gauze.  Though  this  was  done  with  all  gentleness,  it  was  soon  after  noticed 
that  blood  was  trickling  from  the  vagina.  On  removal  of  the  strips,  two  small  lacera- 
tions on  the  right  side  of  the  vagina,  near  the  orifice,  the  parts  here  being  exceedingly 
pulpy  and  vascular,  were  oozing  freely.  This  was  arrested  by  tying  up  the  bleeding 
points  with  chromic  gut.  The  vagina  was  again  irrigated  and  insufflated,  but  na 
further  trial  of  plugging  was  made.  As  soon  as  the  patient  was  replaced  in  bed,  a  soft 
catheter  was  inserted  to  empty  into  a  "  slipper."  The  recovery  was  rapid  and  without 
drawbacks.  The  ten  sutures  were  removed  on  the  eighth  day  with  the  aid  of  chloro- 
form. The  catheter  was  retained  till  the  twelfth  day,  when  the  patient  was  allowed  to 
get  on  a  sofa.  She  left  the  hospital  seventeen  days  after  the  operation.  Dr.  Day 
wrote,  on  March  19,  that  the  patient  had  been  safely  confined  without  any  trouble 
with  the  lithotomy  incision. 

The  first  question  to  decide  here  was  whether  to  operate  at  once  or 
to  let  the  pregnancy  (ah-eady  advanced  to  six  months  and  a  half)  be 
first  concluded.  While  the  stone  itself  was  not  large  enough  to  have 
interfered  with  labour,  both  Dr.  Day  and  I  thought  that,  if  the  bladder 
were  allowed  to  remain  in  its  present  state  for  another  two  months  and 
a  half,  the  cystitis  would  be  rendered  much  more  difficult  of  treatment,, 
intensified,  as  it  Avas  likely  to  be,  by  a  lingering  and  difficult  confine- 
ment, such  as  the  patient  was  liable  to.  It  having  been  decided  that  it 
was  advisable  to  interfere  at  once,  the  choice  lay  between  (i)  dilatation 
of  the  urethra,  (2)  litholapaxi/,  and  (3)  lithotomy,  (i)  Dilatation. — The 
size  of  the  stone  at  once  put  this  aside.  Though  small  (240  gr.),  it  waS' 
a  full  inch  in  one  diameter,  and  just  over  three-quarters  of  an  inch  in 
the  other.  With  such  a  stone  (a  hard  one,  of  lithic  acid  and  lithates), 
there  was  a  ver}^  serious  risk  of  after-incontinence  (especially  when  the 
blades  of  a  small  forceps  have  to  be  taken  into  consideration  as  well). 

(2)  ]jitholapaxi/. — If  it  had  not  been  for  the  co-existing  pregnancy,  the 
stone  might  well  have  been  thus  dealt  with.  But  as  great  irritability 
of  the  bladder  was  present,  in  addition  to  the  pregnancy,  it  was  thought 
that  litholapaxy  was  more  likely  to  require  a  prolonged  ansesthetic  and 
to  cause  greater  disturbance  of  some  important  pelvic  and  abdominal 
viscera  than  the  remarkably  simple  and  rapid  vaginal  lithotomy.  It 
will  be  remembered  that  the  way  in  which  the  aniiesthetic  would  be 
taken,  and  its  after-results,  were  more  than  ever  matters  of  uncertainty 
in  this  case.  If  the  anaesthetic  had  been  badlj'  taken,  we  had  to  face 
the  risks,  on  the  one  hand,  of  premature  labour  coming  on,  and,  on  the 
other,  of  difficulty  in  completing  the  operation,  and  thus  of  fragments 
being  left  behind,  which  would  intensify  the  already  existing  cj^stitis. 

(3)  Lithotomy. — It  being  decided  to  resort  to  this,  the  vaginal  method 
was  chosen  from  its  great  simplicity,  the  small  amount  of  anaesthetic 
required,  and  the  facilities  which  it  gave  for  washing  out  the  bladder 
at  the  time  of  the  operation. 

Suj^ra-jndnc  Lithotomy. — This  has  been  fully  described  at  p.  400. 
The  fiuid  is  retained  in  the  bladder  by  finger-pressure  upon  the  orifice 
of  the  urethra. 

B.  In  Children. — Some  of  the  conclusions  which  Mr.  Walsham  has 


CYSTOTOMY.  427 

drawn    in    a  vevy  helpful    paper    {St.  Barthol.  Hasp.  Beports,  vol.  xi. 
p.   1 29)  may  be  quoted  here : 

For  small  stones  rapid  dilatation  iinder  chloroform  is  better,  as  caus- 
ing less  annoyance  'and  inconvenience  to  the  patient.  That  moderate- 
and  even  large-sized  stones  have  been  removed  by  dilatation,  but  that, 
as  incontinence  has  frequently  followed  from  over-distension,  it  is  not 
justifiable  to  subject  the  patient  to  this  risk.  That,  after  limited 
dilatation,  should  the  stone  appear  larger  than  was  anticipated,  it 
may  be  crushed  with  safety ;  but,  should  crushing  be  considered 
unadvisable  or  impossible,  it  is  better  to  perform  vaginal  lithotomy 
than  subject  the  patient  to  any  risk  of  incontinence  by  ovei'-dilatation. 
That  it  is  not  safe  to  aid  the  dilatation  by  incising  the  urethral  walls. 
That  incision  of  the  urethra  alone,  without  dilatation,  in  whatever 
direction  practised,  is  frecpiently  attended  with  incontinence,  and 
should  therefore  be  abandoned.  That  moderate  and  even  large  stones 
can  be  easily  removed  from  young  children  by  vaginal  lithotomy, 
aided,  if  necessary,  by  dilatation  of  the  vagina,  incision  of  the  four- 
chette,  and  crushing  of  the  stone  by  the  wound  made  through  the 
septum,  without  any  risk  of  a  permanent  vesico-vaginal  fistula  so  long 
as  the  edges  of  the  incision  are  not  bruised  in  the  extraction. 

Mr.  Walsham  considers  each  of  the  above  and  several  other  points 
separately,  and  supports  them  with  evidence.  I  think  that  this  tends 
to  show,  in  the  case  of  vaginal  lithotomy,  that,  though  a  stone  may  be 
thus  extracted  after  dilatation  of  the  vagina,  division  of  the  fourchette, 
and  destruction  of  the  hymen,  it  is  by  no  means  easy  in  these  cases  to 
insert  sutures  satisfactorily.  It  will  be  wiser,  I  think,  to  make  use  of 
the  supra-pubic  operation  in  female  children  for  all  save  the  very 
smallest  stones.  Litholapaxy,  although  by  no  means  easy  in  these 
small  bladders,  is,  however,  held  by  Mr.  Keegan  {Ind.  Med.  Bee, 
Aug.  I,  1897)  to  be  the  correct  treatment  in  the  great  majority  of 
cases  of  vesical  calculus  in  women  and  girls. 

I  would  refer  my  readers  to  a  case  of  supra-pubic  operation  by  Mr. 
Barwell  in  a  child,  aged  9,  from  whom  a  stone  weighing  two  and  a 
quarter  ounces  was  successfully  removed.  It  is  interesting  to  note 
that  Mr.  Barwell  was  led  to  adopt  the  supra-pubic  operation  from  his 
having  had  within  seven  months  no  less  than  three  cases  of  vesico- 
vaginal fistuloe  originating  in  the  extraction  of  calculi  during  infanc}- 
and  youth  b}'  different  surgeons  (Med.-Chir.  Trans.,  vol.  Ixix.  p.  342). 


CYSTOTOMY. 

Indications. — The  operation  of  opening  the  bladder,  apart  from  such 
cases  as  exploring  for  growth,  foreign  body,  &c.,  may  be  required  in  : 

I.  Some  cases  of  cystitis.  When  the  urine  is  foetid  and  slimy. 
When  pain  in  the  bladder  and  penis  is  intense,  leading  to  loss  of 
sleep  and  appetite.  When  there  is  a  high  temperature  and  other 
evidence  of  imminent  septicemia.  When  all  other  treatment  has 
failed,  and  when  washing  out  is  insufficient  or  unendurable. 

The  operation  here,  for  the  sake  of  the  kidneys,  must  not  be   put 


428  OPERATIONS  OX  THE  ABDOMEN. 

off  too  late.  Mucli  benefit  mar  be  obtained  by  irrigating  the  bladder 
freely,  and  afterwards  mopping  it  out  with  a  small  sponge  and  a 
solution  of  silver  nitrate,  3ss  or  ,~j — §j. 

2.  Some  cases  of  great  irritability  of  the  bladder  persisting  after 
dilatation  of  a  stricture.  Mr.  R.  Harrison  (Surg.  Bis.  of  the  Urin. 
Org.,  p.  201)  believes  that  the  continuance  of  the  irritability^  in 
these  cases  is  due  to  the  muscular  hypertroplw  which  the  bladder 
has  undergone  in  its  constant  endeavours  to  force  urine  through  the 
obstruction  in  front  of  it,  and  that  the  cystotomy  is  curative  by 
bringing  about  atrophy  or  loss  of  that  muscularitj'. 

3.  Some  cases  of  tubercular  cystitis  (p.   385). 

4.  As  part  of  other  operations.  Thus,  in  plastic  operations  about 
the  urethra,  to  keep  the  parts  dry.  the  bladder  may  be  opened.  I 
have  done  this  in  a  case  of  epispadias. 

5.  As  this  operation  will  not  again  be  alluded  to,  I  may  remind 
my  readers  that  cystotomy,  or.  rather,  opening  the  prostatic  urethra 
on  a  staff,  has  been  recommended  by  Sir  H.  Thompson  (Dis.  of  the 
Prostate,  ]>.  176)  in  those  few  but  most  distressing  cases  of  enlarged 
prostate  leading  to  hourly  catheterism,  cystitis,  loss  of  sleep,  and 
other  aggravated  sym2:)toms. 

6.  Supra-pubic  cystotomy  is  employed  occasionally  in  Hunter's 
method  of  treating  stricture  by  passing  a  sound  from  the  bladder 
up  to  the  perinasum. 

Supra-pubic  cystotomy  for  drainage  of  the  bladder.  A  helpful 
account  of  this  method  is  given  by  Mr.  Bond  (Lancet,  vol.  ii.  1889, 
p.  260).  The  distended  bladder  having  been  incised  above  the  pubes 
in  the  ordinary  Avay,  the  urethral  orifice  is  felt  for  with  the  forefinger, 
and  a  curved  staff  ])assed  until  it  bulges  in  the  perineum  just  below 
the  bulb.  The  patient  being  placed  in  lithotomy  position,  the  point 
of  the  staff  is  cut  down  upon,  pushed  through,  and  a  rubber  tube 
attached  to  it.  This  tidie,  with  one  or  t^\■o  openings  in  it,  is  drawn 
through  above  the  pubes.  In  a  few  days  it  may  l^e  drawn  into  the 
bladder  from  below,  and  a  little  later  withdrawn  altogether. 

Where  the  supra-pubic  and  perinjeal  incisions  have  been  made  use 
of  for  a  stricture  which  cannot  be  dilated  from  the  front,  the  curved 
sound  is  removed  as  soon  as  the  perinteum  has  been  opened,  and  the 
stricture  thoroughly  divided.  A  grooved  director  is  then  passed  from 
the  perinaBum  into  the  bladder,  and  upon  this,  as  a  guide,  a  full- 
sized  catheter  is  passed  from  the  urethra  into  the  bladder  and  tied  in. 
See  a  case  of  traumatic  stricture  thus  treated  by  Mr.  Howse  (Cl'm.  Sac. 
Trans.,  vol.  xii.  p.  9). 

The  above  are  instances  of  cases  calling  for  cystotomy.  The  surgeon 
will  have  to  choose  between  three  operations — viz.,  median  and  supra- 
pubic cystotomy  and  external  iirethrotomy.  Tiie  median  operation  is 
almost  ah\'ays  to  be  preferred  to  the  lateral,  but  it  is  probable  that 
external  urethrotomy  (p.  437)  ^^■ill  be  sufficient  in  most  cases  as  to 
drainage,  and  it  is  certain  that  this  operation  is  less  risky  from 
shock,  cellulitis,  and  secondary  haemorrhage.  The  great  object  is  to 
drain  the  cavity  thoroughly. 


RUPTURED  r.LADDEE.  429 


RUPTURED    BLADDER. 


The  treatment  of  this  hitherto  most  fatal  injury  has  ni'  late  years 
been  cleared  up.''  Exploratory  operations  and  suture  of  the  bladder 
will  be  increasingly  successful  in  favourable  cases — i.e.,  those  seen 
early  and  those  in  which  the  injury  is  limited  to  the  bladder. 

Tiro  forms  of  ruphire  are  recognised — the  intra-  and  exti'a-peritonfeal. 
It  may  be  well  to  state,  succinctly,  the  sj'mptoms. 

Intra -peritoiueal  L'uphire. — (i)  History  of  a  likely  injury.  (2)  In- 
ability to  pass  water,  t  This  power  has,  however,  been  preserved  in 
both  varieties  :  naturally  it  is  seen  most  frequently  and  more  com- 
pletel}^  in  extra-peritona?al  cases.  It  is  very  rarely  normal  in 
the  intra-periton»al  ruptures.  (3)  A  little  bloody  urine  drawn 
off  with  a  catheter.  (4)  Difficulty  of  manipulating  an  instru- 
ment in  a  contracted  bladder.  (5)  If  the  catheter,  hitting  off  the 
rent,  be  passed  beyond  the  bladder,  a  much  larger  quantity'  of  blood- 
stained fluid  is  withdrawn,  partly  urine,  partly  serum,  from  irritation  of 
the  peritonasum.  If  the  flow  through  the  catheter  is  markedly 
increased  by  inspiration  and  diminished  by  expiration,  the  rent  is 
probably  a  lai'ge  one.  (6)  Speedy  (usuall}')  supervention  of  peritonitis. 
(7)   Perhaps  fluctuation  and  shifting  dulness  in  the  flanks. 

Exira-peritona'ol  Rupture. — (ij  History  of  a  likely  injury.  (2) 
Inability  to  pass  water  (vide  supra).  (3)  A  little  bloody  urine  drawn 
off.  (4)  The  catheter  finds  the  bladder  contracted.  (5)  No  tapping  of 
a  larger  amount  of  fluid.  (6)  Evidence  of  extravasation  rather  than 
of  peritonitis.  Tlius,  if  the  rent  is  in  front,  the  urine  may  be  localised 
there  with  circumscribed  dulness ;  or  widely  diffused,  mounting  up 
towards  the  umbilicus,  between  the  abdominal  muscles  and  the 
peritonaeum  ;  or  passing  into  the  iliac  fossae,  or,  by  the  canals,  into  the 
scrotum  and  thighs. 

It  nnist  be  remembered  that  the  following  may  mislead :  There  may 
be  very  little  pain  complained  of;  no  sickness;  a  normal  temperature; 
the  patient  may  be  able  to  walk  ;  upwards  of  half  a  pint  of  urine  may 
be  drawn  off  night  and  morning,  and  yet  the  peritongeal  sac  may  contain 
much  fluid.  Peritonitis  may  be  absent  post-mortem,  though  tympanites 
be  present  during  life,  and  though  fluid  be  found  in  the  peritonaeal  sac. 
The  patient  may  live  as  long  as  five  days,  apparently  improving,  and 
then  die  suddenly. 

The  following  may  be  useful  in  doubtful  cases: 

Mr.  Walsham  in  his  second  case  (Trans.  Afed.-Chir.  Soc,  vol.  Ixxviii. 
p.  278),  to  make  certain  of  the  existence  of  a  rupture,  made  use  of  the 
injection  of  air,  the  injection  of  fluid  not  being  conclusive.  "  For  this 
purpose  the  india-rubber  apparatus  belonging  to  an  ether-freezing 
microtome  was  utilised,  the  tube  of  which  was  attached  to  the  free  end 

*  Especially  by  Sir  "W.  Mac  Cormac's  paper,  with  two  successful  cases.  Lancet.  1886, 
vol.  ii.  p.  118.  Many  others  have  followed.  Mr.  Walsham  has  been  able  to  report  two 
successful  cases  {Trans.  Mi'd.-Chlr.  Soc.  1886  ami  1895). 

t  Thus  the  rent  may  be  valvular  or  blocked  by  intestine,  &c.  On  all  these  and  many 
other  points  the  reader  should  refer  to  Mr.  Eivington's  writings,  Diet,  of  Surg.,  vol.  i. 
p.  152.  a,nd  liiipture  0/ the  Urinary  Bladder,  for  exhaustive  completeness  and  helpful 
information. 


430  OPERATIONS   ON  THE  ABDOMEN. 

of  the  catheter.  The  liver  duhiess  having  been  carefully  percussed 
out,  a  few  cubic  inches  of  air  were  forced  through  the  catheter  by  two 
or  three  contractions  of  the  rubber  ball.  The  effect  was  instantaneous. 
The  abdominal  cavity  became  distended,  the  liver  dulness  imme- 
diately effaced,  and  the  whole  abdomen  tympanitic  to  percussion. 
The  patient  fell  into  a  condition  closely  resembling  collapse ;  he 
complained  of  great  pain,  his  respiration  was  laboured,  and  the  action  of 
the  heart  turbulent." 

This  method  was  recommended  bj'  two  American  surgeons.  Dr. 
Morton  and  Professor  Keen,  independently,  in  1 890.  Mr.  Walsham  was 
the  first  to  employ  it. 

Operation. — The  patient  being  under  an  anaesthetic,  the  abdominal 
wall  cleansed  and  shaved,  and  the  parts  relaxed.*  a  free  incision  five  or 
six  inches  long  in  the  adult,  is  made  in  the  middle  line.  The  linea  alba 
having  been  divided,  the  recti  retracted  and  parth'  detached  if  needful, 
all  bleeding  points  secured,  the  lower  angle  of  the  wound  and  the  parts 
behind  the  pubes  are  carefully  examined  for  ecchymosis,  extravasation, 
&c.  If  neither  of  these  nor  anj^  collection  of  fluid  is  found  outside  the 
peritonaeum,  this  is  opened,  when  a  large  gush  of  fluid  may  be  decisive. 
The  surgeon  now  introduces  one  finger  to  feel  for  the  rent,  and  the 
detection  of  this  may  be  facilitated  by  passing  a  short-beaked  sound. 
The  rent  will  vary  in  site  and  length, f  and  also  as  to  regularity, 
thickening,  &c.  If  it  be  a  long  one,  and  reach  downwards  towards  the 
recto- vesical  cul-de-sac  the  introduction  of  a  rectal  bag  (Fig.  163, 
p.  400),  may  be  of  assistance.  Sir  W.  Mac  Cormac  also  found  that  the 
bladder  came  up  more  readily  after  the  parietal  peritonaeum  had  been 
transversel}^  divided  on  each  side.  An  assistant  with  carefully  cleansed 
hands  may  render  service  at  this  time  by  hooking  up  the  bladder  with 
two  fingers,  while  the  intestines  are  kept  back  with  sponges.  The  rent, 
being  now  in  view,  is  cleansed,  and  sutures  of  fine  carbolised  silk 
inserted.  The  shortest  possible  needle  should  be  employed  here, 
owing  to  the  depth  of  the  wound  and  the  limited  space  there  is  to 
work  in.  Mr.  Walsham  in  his  second  case  found  that  a  T.  Smith's 
rectangular  palate-needle  answered  admirably  in  inserting  the  deepest 
sutures.  All  of  these  should  be  put  in  before  any  are  tied,  and  if 
the  first  are  gently  drawn  upon  it  will  facilitate  the  insertion  of  the 
others.:]:  Sir  W.  Mac  Cormac  used  sixteen  sutures  in  one  •  case  and 
twelve  in  another,  and  his  success  is  largely  due  to  the  great  care  with 
which  they  were  inserted.  Thus,  they  were  put  in  a  quarter  of  an  inch 
apart,  after  Lembert's  method  (Fig.  55,  p.  228).  including  the  serous 
and  muscular  coats  only,  beginning  at  the  lower  part,  the  first  and  last 
sutures  being  inserted  well  beyond  the  limits  of  the  injury  so  as  to 
prevent  leakage  from  the  extremities.  The  following  precautions  are 
taken  in  passing  tliem :  Fine  curved  needles  are  used  in  holders ;  the 

*  In  Mr.  Willett's  case  (<SY.  Barthol.  Hosp.  Reports,  vol.  xii.  p.  209)  much  difficulty 
was  met  with  from  the  rigidity  of  the  abdominal  walls,  and  the  great  distension 
of  the  intestines,  which  kept  crowding  out  of  the  wound,  and  were  most  difficult  to 
replace.  Peritonitis  had  set  in  here,  twenty-four  hours  having  elapsed  since  the 
injury. 

f  In  Sir  W.  Mac  Cormac's  cases  the  rents  were  four  and  two  inches  long. 

:J:  In  this  case  the  rent  was  in  the  posterior  wall  extending  from  the  summit  along 
the  middle  line  to  the  base  of  the  trigone. 


PUNCTURE  OF  THE  BLADDEE.  43 1 

serous  surfaces  are  carefully  inverted.  The  insertion  of  a  finger  into  the 
rent  will  facilitate  the  passage  of  the  deepest  sutures.  The  sutures  are 
passed  through  the  serous  and  muscular  coats  only.  This  avoids  the 
risk  of  traversing  the  mucous  membrane,  which  in  animals  has  nearly 
always  proved  fatal,  because — (i)  on  tightening  the  sutures,  the 
mucous  membrane  falls  between  the  edges  of  the  wound  and  hinders 
union  ;  (2)  the  urine  may  find  a  channel  through  the  points  of 
passage  of  a  suture,  and  so  into  the  cavity  of  the  peritonaeum ;  (3)  the 
loop  of  suture  A\'ithin  the  bladder  is  a  foreign  body,  and  salts  may  be 
deposited  on  it. 

Wherever  a  gap  appears,  another  suture  should  be  inserted.  If  there 
is  time,  a  few  of  chromic  gut  may  be  inserted  through  the  serous  coat 
only,*  but  Sir  W.  Mac  Cormac  regards  the  double  row  as  unnecessary ; 
8  or  10  oz.  of  boracic  acid  are  then  injected  into  the  bladder,  to  see  if  it 
is  water-tight ;  or  a  coloured  fluid,  such  as  Condy's  lotion,  may  be  used. 
A  few  more  sutures  may  be  required  till  this  fact  is  absolutely 
certain.  The  peritonseal  cavity  is  now  most  carefully  wiped  out  with 
sponges  on  ovariotomy  clamp-forceps,  pushed  well  down  into  the  pelvis 
and  the  flanks  till  they  come  out  clean  and  dry  on  squeezing. 

Where  the  surgeon  is  doubtful  about  the  state  of  the  peritonasal 
sac,  or  where  irrigation  has  been  used,  a  glass  tube  should  be  left  in  the 
pelvic  pouch  and  sucked  out.  A  catheter  should  be  passed  at  regular 
intervals. 

Cases  occasionally  occur  where  the  neck  and  not  the  body  of  the 
bladder  is  lacerated,  a  fracture  of  the  pelvis  perhaps  co-existing. 
Where  there  is  inability  to  pass  water  and  where  it  is  uncertain 
whether  a  catheter  enters  the  bladder,  it  will  be  best  to  explore  the 
front  and  neck  of  the  bladder  by  a  supra-pubic  incision  not  opening 
the  peritonaeum.  If  blood-stained  fluid  well  up,  and  if  the  catheter  be 
detached  h^ing  outside  the  bladder,  the  bladder  should  be  opened  and  a 
curved  staff  passed  through  the  urethra  and  cut  down  upon  in  the 
peringeum.  A  drainage-tube  should  then  be  passed  according  to  the 
directions  given  at  p.  428. 

This  will  drain  the  bladder  effectuall}-,  and  pi-event  any  further 
escape  of  urine.  The  space  outside  the  bladder,  around  its  neck,  must 
be  cleaned  thoroughly  b}^  the  supra-pubic  incision,  tamponnaded  with 
iodoform  gauze,  and,  if  needful,  drained  from  the  perinaeum. 


PUNCTURE  OP  THE  BLADDER. 

The  following  methods  will  be  considered  here : 

i.  The  Aspirator. 
ii.  Supra-pubic  Puncture. 
iii.  Puncture  per  Rectum. 
iv.  Puncturp  through  the  Prostate. 

i.  The  Aspirator. — This  maj^  be  used  in  cases  of  great  urgency, 
when  the  surgeon  is  compelled  to  relieve  retention  without  regard  to 


*  Sutures  through  the  serous  coat  only  invariably  giveaway. 


432  OPERATIONS  OX  THE  ABDOMEN. 

the  cause ;  when  he  is  without  the  means  of  carrying  out  other  and 
perhaps  better  methods  ;  it  is  especially  suited  to  those  cases  in  which 
there  is  reason  to  believe  that  urine  will  again,  in  a  few  hours,  be 
passed  by  the  urethra.  Thus,  in  gonorrhoeal  retention  where  a  catheter 
cannot  be  passed,  having  perhaps  been  clumsily  used,  and  where  relief 
is  urgently  required  ;  where  retention  has  supervened  on  a  stricture  of 
only  two  or  thi*ee  years'  standing,  this  means  may  be  used  successfully, 
giving  time  for  warm  baths  and  opium  to  act.  In  an  old  stricture,  in 
one  of  traumatic  origin,  or  in  a  case  of  enlarged  prostate,  it  can  only  be 
a  temporary  measure,  and  should  only  be  used  when  other  instruments 
are  not  available. 

The  question  arises,  How  far  n-lll  asptraiioib  hear  repetition?  This  is  quite  uncertain. 
On  the  one  hand,  in  a  case  of  prostatic  retention  not  admitting  a  catheter,  the  patient 
being,  throughout,  in  a  most  grave  condition.  Dr.  Brown  {Brit.  Med.  Jonrn..  May  23, 
1874)  used  the  aspirator  fifteen  times  between  January  2nd  and  12th,  "  with  imme- 
diate relief  on  every  occasion,  and  without  the  smallest  inconvenience  or  injury  from 
the  punctures."  Mr.  Hague  {Lancet,  1885,  vol.  ii.  p.  385),  in  a  patient,  aged  90,  with 
prostatic  retention  of  forty-eight  hours'  duration,  aspirated,  and  continued  to  do  so 
daily  for  nearly  five  weeks,  as  no  catheter  could  be  passed.  Such  numerous  aspira- 
tions caused  no  ill  effects. 

On  the  other  hand,  in  a  case  of  mine  of  prostatic  retention  in  which  the  aspirator 
had  been  used  only  three  times,  on  the  death  of  the  patient  from  bronchitis  on 
the  fourth  day,  the  third  and  last  puncture  was  found  to  be  leaking.  Dr.  Campbell 
{Brit.  Med.  Jonrn.,  Feb.  21,  1886)  records  a  case  in  which  the  bladder  had  been 
aspirated  twice,  and  internal  urethrotomy  then  performed  :  "  progress  was  good  for  a 
day  or  two,  when  some  inflammation  appeared  at  one  of  the  punctures,  an  abscess 
formed,  peritonitis  came  on,  and  the  man  died."  Where  aspiration  is  to  be  iiscd,  the 
condition  of  the  bladder  walls  and  of  the  urine  must  be  taken  into  account.* 

If  aspiration  be  made  use  of,  a  fine  needle  should  be  employed,  and 
introduced  just  above  the  pubes  while  an  assistant  steadies  the  bladder 
by  pressure  on  either  side.  The  bladder  must  not  be  allowed  to  become 
much  distended  before  the  puncture  is  repeated,  otherwise  urine  may 
be  forced  out. 

ii.  Supra-pubic  Puncture. — This  operation  has  the  advantarfes 
of  being  easil\"  })erforuied,  of  giving  permanent  relief  if  desired,  and  of 
being  safe. 

The  two  ohjedions  brought  against  it  are,  that  (i)  it  gives  bad 
drainage,  and  (2)  it  is  liable  to  extravasation.!  Neither  of  these  is 
borne  out  by  facts.  While  the  patient  is  in  bed,  good  drainage  can  be 
provided  by  turning  him  on  one  side  and  attaching  tubing  to  the  can- 
luila  ;  when  the  patient  is  up  (and  a  cannula  so  placed  is  no  drawback  to 
this),  the  power  of  micturition  will  jn-obably  have  returned.  In  a  few 
cases  of  enlarged  i:)rostate  the  patient  Avill  be  compelled  to  pass  his 
urine  this  way  for  the  rest  of  his  life,  but  as  soon  as  the  parts  are 

'■■•  Mr.  Bennett  read  a  case  before  the  Medico-Chirurgical  Society  {Lancet,  1888, 
vol.  i.  p.  418)  of  extra-pcritonical  rupture  of  the  bladder  after  aspiration  in  a  patient 
long  the  subject  of  stricture.  The  opinion  of  most  surgeons  present  seemed  to  be  that 
aspiration  was  dangerously  liable  to  leakage,  especially  in  unhealthy  bladders. 

f  Mr.  T.  Smith  {St.  Barthol.  Honp.  Ilepods,  vol.  xvii.  p.  291)  writes :  "  I  have 
seen  no  such  tendency  to  extravasation ;  occasionally  there  is  some  inconvenience 
from  leakage  :  this  may  be  met  by  leaving  out  the  cannula  for  a  few  hours,  which 
allows  recontraction  to  take  place. 


PUNCTURE  OF  THE  BLADDER.  433 

consolidated  around  the  cannula,  or  the  catheter  which  has  replaced  the 
cannula,  micturition,  though  tedious,  will  be  effected  satisfactorily. 

I  may  allude  to  three  cases  out  of  many  in  which  I  have  used  this 
method — two  of  retention  with  stricture,  one  of  prostatic  retention. 
I  consider  it  the  best  all-round  method,  and  the  one  of  widest  applica- 
tion that  we  have.  Its  relief  is  immediate,  safe,  and  simple  withal. 
The  two  cases  of  stricture  were  men  under  40,  admitted  with  a  history 
of  catheterism,  bleeding  urethras,  and  recent  false  passages.  On  the 
fifth  and  second  day  I  was  able  to  pass  a  No.  7  silver,  and,  in  the 
third  case,  a  coudee  catheter.  For  some  cases  of  older  strictures, 
especially  if  -with  fistulas  and  a  damaged  perina3um.  a  longer  rest  is 
required,  and  Mr.  Cock's  or  Mr.  Wheelhouse's  operation  is  indicated. 

Operation. — This  is  most  simple.  A  median  puncture  having  been 
made  through  the  skin  just  above  the  shaved  pubes,  the  trocar  is 
inserted.  I  prefer  a  curved  trocar  and  cannula,  the  latter  carrying 
tape-holes,  but  a  straight  trocar  and  cannula  may  be  used,  through 
which  an  8  or  9  gum-elastic  catheter,  or,  better,  a  Jacques'  catheter,  is 
inserted  ;  in  four  hours  the  cannula  can  be  removed,  and  a  large  catheter, 
a  10  or  12,  introduced.*  To  keep  the  cannula  firm  at  first,  I  insert  a 
silver  suture  in  the  puncture,  cover  this  with  iodoform  and  collodion, 
and  pack  some  strips  of  dry  gauze  around.  I  generally  give  a  little 
anaesthetic,  but  this  is  not  needed.     The  skin  puncture  is  alone  painful. 

iii.  Puncture  per  Rectum. — This  has  the  advantage  of  draining  a 
bladder  well,  but  there  are  such  serious  disadvantages  connected  with  it 
that  the  supra-pubic  operation  is  always  to  be  preferred  to  it. 

Thus  (i)  it  is  difficult  and  most  unpleasant  to  the  patient  to  retain 
the  cannula  during  defsecation  and  passage  of  flatus — the  retention  of 
a  cannula  is  liable  to  cause  troublesome  tenesmus  and  diarrhoea  ;  (2) 
when  the  cannula  slips  out  it  is  difficult  to  replace  it ;  f  (3)  the  patient 
is  kept  in  bed ;  (4)  this  method  is  not  applicable  to  cases  of  enlarged 
prostate.  lam  aware  that  Mr.  Bryant  {Sunjerii,  vol.  ii.  p.  153)  states 
that  "  an  enlarged  2:)rostate  is  no  real  obstacle  to  its  performance,  for 
this,  if  necessary,  may  be  perforated  with  impunity.'"  I  cannot  at  all 
agree  with  the  above,  in  spite  of  Mr.  Bryant's  authority.  Being  one  of 
those  who  look  upon  aji  enlarged  prostate,  especially  when  congested 
with  retention,  and  surrounded  by  an  enlarged  venous  plexus,  as  a 
structiu-e  to  be  ti'eated  with  great  respect,  I  think  that  there  is  an 
undoubted  risk  that  perforating  it  may  lead  to  septic  phlebitis  and 
abscess,  and  to  suppuration  in  already  impaired  kidneys. 

Mr.  Bryant  (Joe.  supra  cit.)  speaks  very  highly  of  puncture  per 
rectum,  and  saj's  that  the  objections  raised  against  it  are  theoretical 
onh^ — viz.,  abscess  between  the  bladder  and  rectum,  persistent  fistulous 
opening,  injury  to  the  vesiculte  seminales  or  the  peritonaeum,  I  do  not 
deny  that  these  injuries  are  rare,  but,  as  compared  with  supra-pubic 


*  If  an  aspirator  has  been  used,  ami  it  is  desired  to  replace  it  with  a  catheter, 
a  catgut  bougie  should  be  passed  through  the  cannula,  and,  this  being  \vithdra%vn, 
a  small  gum-elastic  catheter,  with  an  eye  in  its  point,  is  passed  over  the  bougie. 
Larger  ones  can  soon  be  got  in,  passing  them  with  terminal  eyes  over  the  smaller 
ones,  or  by  means  of  a  stylet  (T.  Smith). 

t  Thus,  there  are  two  specimens  in  Guy's  Hospital  Museum  proving,  by  the  double 
puncture  present,  that  this  is  the  case. 

VOL.  XL  ^  28 


434  OPERATIONS  ON  THE   ABDOMEN. 

puncture,  the  drawbacks  which  I  have  given  above  are  practical  and 
undoubted. 

Operation. — If  this  method  is  emploj^ed,  Mr.  Cock's  instruments 
should  be  made  use  of — viz,,  a  ver}-  sharp  and  a  blunt  pilot-trocar,  and 
a  cannula  with  inner  tubes  to  keep  the  cannula  in  position  and  to 
admit  of  its  being  closed.  The  patient  being  in  lithotomj^  position  and 
the  rectum  emptied,  the  surgeon  feels  for  the  distended  bladder,  behind 
the  prostate,  ^\"ith  liis  left  index  finger.  This  being  kept  in  situ,  he 
introduces  the  cannula  and  blunt  pilot  along  the  finger  up  to  the  point 
he  intends  to  puncture.  The  pilot  being  withdrawn,  the  sharjD  trocar  is 
introduced,  and  when  it  is  nearly  up  to  the  hilt  in  the  cannula,  it  is 
depressed  and  then  driven  on  in  a  direction  upwards  and  forwards,  as 
if  aiming  for  the  umbilicus.  The  trocar  is  then  withdrawn,  the  inner 
tubes  inserted,  and  the  whole  secured  with  tapes.  The  urine  is  best 
conveyed  away  by  tubing. 

iv.  Puncture  through  the  Prostate. — Mr.  R.  Harrison*  has  advo- 
cated this  method,  and  published  a  most  successful  case  in  a  patient, 
aged  84,  with  prostatic  retention.  A  special  straight  trocar  was  in- 
troduced in  the  middle  line  three-quarters  of  an  inch  in  front  of  the 
anus,  and  pushed  steadily  through  the  prostate  into  the  bladder,  the 
left  index  being  retained  in  the  rectum.  The  cannula  was  removed  in 
nearly  three  months,  natural  micturition  gradually  returning.  Atrophy- 
of  the  enlarged  prostate  appeared  to  follow,  and  the  sjanptoms  were 
much  relieved. 

I  cannot  but  think  that  this  method  runs  the  risk  of  septic  phlebitis 
(vide  sujrra).  Another  objection  is  that  the  patient  is  kept  in  bed. 
Micturition  becomes  natural  much  more  quickly  after  supra-pubic 
puncture. 


*  Intern.  Encycl.  of  Surg,,  vol.  vi.  p.  414. 


CHAPTER   XII. 
OPERATIONS    ON    THE    URETHRA    AND    PENIS. 

BUPTURED  URETHRA.— EXTERNAL  URETHROTOMY.— 
INTERNAL  URETHROTOMY.  —  CHOICE  OF  OPERA- 
TION FOR  RELIEF  OF  RETENTION.  —  CIRCUM- 
CISION. —  AMPUTATION  OF  PENIS.  —  EPISPADIAS. 
—HYPOSPADIAS. 

RUPTURED     URETHRA. 

In  a  few  cases  the  surgeon  may  succeed  in  passing  a  catheter  into  the 
bladder.  If  he  does  so  in  a  case  where  there  has  been  much  bruising  * 
of  the  perinseum  and  extravasation  of  blood,  a  median  incision  should 
still  be  made  to  allow  of  relief  of  tension  and  escape  of  breaking  down 
clots,  and  so  give  good  drainage.  If  this  is  not  done,  the  probability  is 
great  that  a  little  later,  owing  to  damage  of  soft  parts,  tension  of  blood 
clot,  and  a  little  escape  of  urine  by  the  side  of  the  catheter,  this  step 
will  be  required  at  a  time  when,  from  the  presence  of  septic  fever, 
and  the  condition  of  the  extravasated  blood  and  urine,  the  occasion  is 
less  favourable.  Again,  though  a  catheter  can  be  passed  at  the  time,  it 
by  no  means  follows  that  when,  owing  to  its  being  plugged,  or  from 
some  other  reason,  it  requires  removal  in  a  few  days,  a  fresh  one  can 
be  inserted.  An  incision  will  then  have  to  be  made,  and,  as  already 
stated,  under  conditions  less  favourable. •!* 

When,  as  is  usually  the  case,  a  catheter  cannot  be  passed  into  the 
bladder,  the  patient  is  placed  in  lithotoni}'  position,  and  the  parts 
having  been  shaved  and  cleansed,  a  grooved  staff  of  as  full  size  as 
the  parts  will  admit  is  passed  as  far  as  it  will  go — i.e.,  to  the  site  of  the 
rupture;  it  is  then  made  to  project  in  the  perinteum,  and  the  surgeon, 
entering  a  straight  sharp-pointed  bistoury  in  the  middle  line  at  a  point 
an  inch  to  an  inch  and  a  half  in  front  of  the  anus,  pushes  it  on  till  it 
strikes  the  groove,  and  then  cuts  along  this,  both  upwards  and  down- 
wards, so  as  to  expose  freely  the  spot  at  which  the  urethra  is  ruptured. 
As  the  knife  is  brought  out,  the  skin  wound  is  enlarged  till  this  is 

*  Complete  rupture  of  the  urethra  may  co-exist  with  a  mere  contusion  of  the 
perinjeum,  especially  if  much  temlerness  is  present. 

t  Mr.  Rutherford  (^Glasgow  Hasp.  Rep.)  advises  supra-pubic  puncture  in  addition  to 
any  other  procedure,  and  describes  three  cases  in  which  he  adopted  this  plan  with 
^.dvautasre. 


436  OPERATIONS  OX  THE  ABDOMEX. 

about  an  inch  and  a  half  long,  the  lower  end  being  half  an  inch  in 
front  of  the  anus. 

With  the  finger  clots  are  now  turned  out,  and,  retractors  being 
inserted  deeply,  the  wound  is  sponged  out  thoroughly.  A  good  deal  of 
bleeding  may  now  take  place  from  some  wounded  vessel,  hitherto 
closed  by  extravasated  blood,  or  from  the  crus  penis,  detached  on  one 
side  by  the  violence  which  ruptured  the  urethra,  especially  if  there  be  a 
fractured  pelvis.  This  hsemorrhage  will  jaeld  to  firm  pressure  or  to 
forci-pressure.  The  anterior  end  of  the  urethra  is  next  readily  found  by 
the  end  of  the  staff,  which  projects  through  it.  The  finding  of  the  deeper 
or  vesical  end,  often  difficult,  will  be  facilitated  by  careful  sponging,  a 
mirror  and  reflected  light,  pressure  above  the  pubes,  and  the  use  of  fine 
probes  or  straight  gum-elastic  catheters.  This  end  often  projects  as 
a  small  clot  or  bleeding-point ;  at  other  times  it  resembles  a  partly 
■  twisted  artery.* 

If  it  be  found,  a  catheter  of  as  large  size  as  possible  should  always  be 
introduced,  if  practicable,  from  the  meatus,  and  then  through  the 
vesical  end  of  the  urethra  into  the  bladder,  guided  by  a  finger  in  the 
wound,  a  Brodie's  probe,  or  a  Teale's  gorget  (Fig.  174).  If  this  be 
found  impracticable,  a  catheter  should  be  passed  into  the  bladder  from 
the  wound.  One  of  these  methods  should  always  be  made  use  of. 
if  possible,  as  it  enables  the  patient  to  be  kept  dry  by  tubing  attached 
to  the  catheter. 

But  if  no  catheter  can  be  got  into  the  bladder,  either  along  the 
penis  or  from  the  wound,  the  surgeon  need  not  worry  himself  as  long  as 
a  free  exit  has  been  given  for  the  urine  and  extravasated  blood.  In 
these  cases  it  is  not  unusual  for  the  bladder  to  become  somewhat 
distended  during  the  first  two  or  three  days,  owing  to  the  urine  not 
escaping  with  sufficient  freedom,  or  to  the  closure  of  the  vesical  end  of 
the  urethra  from  swelling  after  the  injury  and  the  manipulations  to  find 
it,  or  from  the  patient,  if  a  child,  shrinking  from  passing  his  water. 
This  difficulty  will  usually  be  met  by  hot  flannels  frequently  applied  to 
the  abdomen,  and  a  few  doses  of  laudanum,  but  if  it  be  evident  that 
the  urine  does  not  escape  with  sufficient  freedom,  the  surgeon  must 
again  examine  the  wound  with  the  aid  of  an  anaesthetic,  clean  out  any 
fresh  clots,  and  again  try  to  find  the  vesical  end  of  the  urethra,  aided 
noAv,  perhaps,  by  a  better  light. 

If  this  fail,  supra-pubic  tapjDing  or  aspiration,  or  if  the  patient's 
condition  be  good,  making  a  small  supra-pubic  opening  into  the  bladder 
and  thence  passing  a  short  curved  staff  into  the  peringeum  and  so  finding 
the  vesical  end  of  the  urethra  (p.  428),  must  be  resorted  to. 

Urethritis  and  cystitis  are  not  uncommon  in  children.  They  are 
best  met  b}^  as  soon  as  possible,  leaving  out  the  catheter  for  a  while. 

With  regard  to  the  question  of  faying  to  suture  the  urethra,  it  is 
always  advisable,  if  possible,  to  draw  the  ends  of  the  urethra  togethei' 
on  the  catheter,  with  a  fine  curved  needle  on  a  holder,  and  chromic 
gut  or  carbolised  silk.  But  this  will  often  be  found  a  matter  of  great 
difficulty,  and  even  impossible.  When  effected,  it  does  not  diminish 
the  need  of  subsequent  regular  use  of  catheters. 

*  The   farther  li.ack   the  tear,  the  greater,  of  course,  the  difficulty  in   finding  the 
urethra. 


EXTERNAL  URETHROTOMY.  437 


EXTERNAL    URETHROTOMY   (Figs.    172  to    176). 

riiis  operation  includes  the  different  forms  of  perinatal  section  with 
or  without  a  guide — viz..  Syme's.  Wheelhouse's,  and  Cock's  operation. 

By  some,  external  urethrotomy  is  reserved  for  those  cases  such 
as  Syme's.  in  ^\■hich  a  staff"  can  be  passed  through  the  stricture,  and 
"perinseal  section  "  for  those  in  which  no  such  help  is  available — e.g., 
Mr.  Cock's  operation.  As,  however,  these  terms  are  readily  confused  by 
students,  and,  as  in  AVheelhouse's  operation  a  staff"  is  used,  though  it 
cannot  be  passed  through  the  stricture.  I  think  it  preferable  to  em})loy 
the  term  external  urethrotomy,  specifying  which  operation  is  meant  by 
using  the  author's  name — viz.,  Syme's  external  urethrotomy,  &c. 

Syme's  External  Urethrotomy. — Here  the  stricture  is  divided  on 
a  line  staff"  (ruh  infra)  passed  through  it. 

Indications. — This  excellent  operation  is  strongh'  indicated  in 
(i)  cases  of  strictui-e  which  do  "  not  yield  to  dilatation,  or,  rather, 
continue  to  present  S3miptoms  after  being  dilated" — in  other  words, 
to  contractile,  irritable,  and  resilient  strictures,  in  which  dilatation 
is  accompanied  with  much  pain,  or  in  which  it  is  found  that  a  No.  7 
can  perhaps  be  passed  one  day  and  only  a  Xo.  3  a  day  or  two  after ; 
(2)  cases  in  which  rigors  and  constitutional  disturbance  follow  any 
attempt  at  dilatation. 

Operation. — The  patient,  having  been  prepared  by  mild  aperients  and 
bland  liquid  diet  for  the  operation,  is  brought  under  an  anaesthetic,  and 
while  his  legs  hang  over  the  end  of  the  table,  the  surgeon  introduces  a 
Syme's  staff".  This  has  a  narrow  terminal  portion,  which  passes  through 
the  stricture,  a  shoulder  which  rests  upon  the  face  of  the  stricture,  and 
a  wider,  stouter  part  above  the  shoulder  to  make  the  instrument  easier 
to  find  in  the  peringeum.  The  patient  being  placed,  in  a  good  light,  in 
lithotomy  position,  and  the  parts  cleansed  and  shaved,  the  surgeon 
makes  an  incision  exactly  in  the  median  line  down  upon  the  staff", 
exposing  the  wider  portion  above  the  shoulder.  When  the  surgeon 
is  certain  that  this  is  laid  bare,  he  runs  the  knife  forwards  along 
the  groove,  so  as  to  divide  the  stricture  completelj".  The  staff"  is  now 
withdrawn,  and  the  rest  of  the  treatment  must  varj^  somewhat.  If  the 
condition  of  the  patient  admits  of  it,  a  full-sized  gum-elastic  catheter 
should  be  passed  from  the  meatus  into  the  bladder,  guided  by  a  finger  in 
the  wound  or  in  the  rectum,  or  by  a  grooved  director  passed  from  the 
perinajum.  If  the  irritability  of  the  parts  does  not  admit  of  this,  a  gum- 
elastic  catheter  must  be  inserted  from  the  perinajum,  cut  short,  and  kept 
in  situ  with  tapes,  the  ui'ine  running  off",  by  tubing  attached,  into  a 
basin  containing  carbolic  acid  lotion ;  or  Prof.  Syme's  curved  perinseal 
catheter  may  be  emplo^'ed. 

As  soon  as  a  catheter  can  be  passed  from  the  meatus,  it  should  be 
kept  in  for  two  or  three  days,  and  changed,  if  needful,  with  an  anjss- 
thetic  at  first.  As  soon  as  possible,  it  should  be  passed  twice  a  day. 
and  the  patient  should  be  clearly  told  of  the  absolute  necessity  which 
exists  of  keeping  up  the  good  effects  of  the  operation  by  the  passage 
of  an  instrument  at  regular  intervals,  and  of  occasionally  reporting 
himself  to  his  surgeon. 

Wheelhouse's  External  Urethrotomy. — Here  the  stricture  is  first 


438  OPEEATIONS  ON  THE  ABDOMEX. 

found  by  a  staff  passed  down  to  it,  and  then  divided  on  a  fine  probe- 
pointed  director  passed  through  it. 

Mr.  Wheelhouse  (Brit.  Med.  Journ.,  June  24,  1876)  recommends  his 
method  as  having  "the  advantage  of  greatly  increased  precision;  it 
renders  an  operation,  confessedly  hitherto  one  of  the  most  difficult  in 
surgerj^,  a  comparatively  easy  one,  and  one  which,  in  my  hands  and  in 
those  of  my  colleagues,  has  given  results  infinitely  more  favourable, 
with  an  immediate  and  ultimate  effect  upon  our  cases,  than  we  had 
ever  seen  before  its  introduction." 

Operation. — "  The  patient  is  placed  in  lithotom}^  position,  with  the 
pelvis  a  little  elevated,  so  as  to  permit  the  light  to  fall  well  upon  it, 
and  into  the  wound  to  be  made.     The  staff*  (Fig.  172) 
Fig.  172.  is  to  be  introduced  with  the  groove  looking  toward  the 

surface  and  brought  gently  into  contact  with  the  stricture. 
It  should  not  be  pressed  much  against  the  stricture,  for 
fear  of  tearing  the  tissues  of  the  urethra  and  causing  it 
to  leave  the  canal,  which  would  mar  the  whole  after- 
proceedings,  which  depend  ujDon  the  urethra  being  opened 
a  quarter  of  an  inch  in  front  of  the  stricture.  Whilst  an 
assistant  holds  the  staff  in  this  position,  an  incision  is 
made  into  the  perinseum,  extending  from  opposite  the 
point  of  reflection  of  the  superficial  fascia  to  the  outer 
edge  of  the  sphincter  ani.  The  tissues  of  the  perinseum 
are  to  be  steadily  divided  until  the  urethra  is  reached. 
This  is  now  to  be  opened,  in  the  groove  of  the  staff,  not 
tq'ion  its  point,  so  as  certainly  to  secure  a  quarter  of  an 
inch  of  healthy  tube  immediately  in  front  of  the  stricture. 
As  soon  as  the  urethra  is  opened,  and  the  groove  in  the 
staff  fully  exposed,  the  edges  of  the  healthy  urethra  are 
to  be  seized  on  each  side  with  straight-bladed  nibbed 
forceps  and  held  apart.  The  staff  is  then  to  be  gently 
withdrawn  until  the  button-point  appears  in  the  wound. 
It  is  then  to  be  turned  round,  so  that  the  groove  may  look 
to  the  pubes  and  the  button  may  be  hooked  on  to  the  upper 
(Wheelhouse.)  angle  of  the  opened  urethra,  M-hich  is  then  held  stretched 
open  at  three  points  thus  (Fig.  173),  and  the  operator  looks 
into  it  immediately  in  front  of  the  stricture.  While  thiis  held  open,  a 
probe-pointed  director  f  is  inserted  into  the  urethra,  and  the  operator, 
if  he  cannot  see  the  opening  of  the  stricture,  which  is  often  possible, 
generally  succeeds  in  very  quickly  finding  it,  and  passes  the  point 
onwards  through  the  stricture  towards  the  bladder.  The  stricture  is 
sometimes  hidden  amongst  a  crop  of  granulations  or  warty  growths,  in 
the  midst  of  which  the  probe-point  easily  finds  the  true  passage.  The 
director  having  been  passed  into  the  bladder  (its  entrance  into  which  is 
clearly  demonstrated  by  the  freedom  of  its  movements),  its  groove  is 
turned  downwards,  the  whole  length  of  the  stricture  is  carefully  and 


*  This  is  fully  grooved  through  the  greater  part,  but  not  through  the  whole  of  its 
extent,  the  last  half  inch  of  the  groove  being  "stopped"  and  terminating  in  a  round 
button-like  end. 

t  Or  a  common  blunt-pointed  probe  may  be  used.  Occasionally  a  bougie  (No.  2  or  3) 
is  useful. 


EXTEENAI.  UEETIIROTOMY. 


439 


deliberately  divided  on  its  under  surface,  and  the  passage  is  thus 
cleared.  The  director  is  still  held  in  the  same  position,  and  a  straight 
probe-pointed  bistoury  is  run  along  the  groove  to  ensure  complete 
division  of  all  bands  or  other  obstructions.  These  having  been 
thoroughly  cleared,  the  old  difficulty  of  directing  the  point  of  a  catheter 
through  the  divided  stricture  and  onwards  into  the  bladder  is  to  be 
overcome.     To  effect  this,  the   point  of   a  probe-gorget   (Fig.  174)   is 


Fig.  173. 


Fig.  174. 


Teale's  probe-gorget. 


(Wheelhouse.) 


Fig.  175. 


introduced  into  the  groove  in  the  director,  and,  guided  by  it,  is  passed 
onwards  into  the  bladder  dilating  the  divided  stricture,  and  forming  a 
metallic  floor,  along  which  the  point  of  the  catheter  cannot  fail  to  pass 
securely  into  the  bladder.  The  entry 
of  the  gorget  into  the  latter  viscus 
is  signalised  by  an  immediate  gush 
of  urine  along  it.  A  silver  catheter 
(No.  10  or  11)  is  now  passed  from 
the  meatus  down  into  the  wound,  is 
made  to  pass  once  or  twice  through 
the  divided  urethra,  where  it  can  be 
seen  in  the  wound,  to  render  certain 
the  fact  that  no  obstructing  bands 
have  been  left  undivided,  and  is  then, 
guided  by  the  probe-gorget,  passed 
easily  and  certainly  along  the  pos- 
terior part  of  the  urethra  into  the 
bladder  (Fig.  175).  The  gorget  is 
now  withdrawn,  the  catheter  fastened 
in  the  urethra  and  allowed  to  remain 
for  three  or  four  days,  an  elastic  tube 
conveying  the  urine  away.  After  three  or  four  days  the  catheter  is 
removed,  and  is  then  passed  daily,  or  every  second  or  third  day,  ac- 
cording to  circumstances,  until  the  wound  in  the  perinseum  is  healed ; 
and  after  the  parts  have  become  consolidated,  it  requires,  of  course, 
to  be  passed  still,  from  time  to  time,  to  prevent  reconti'action."  * 


OVheelhouse.) 


*  The  wound  should  be  syringed  occasionally  during  the  operation  with  a  dilute 
solution  of  mercury  perchloride,  and  a  little  iodoform  dusted  iu  at  the  close.     If  any 


440 


OPERATIONS   OX  THE  ABDOMEN. 


This  will  be  found  a  most  effectnal  operation,  but  in  many  cases  the 
hitting-  ofi"  of  the  moiith  of  the  stricture  is  a  less  simple  matter  than 
would  be  gathered  from  Mr.  Wheelhouse's  account.  This  is  especially 
the  case  when  the  parts  are  engorged  and  softened,  as  the  free  oozing 
which  is  met  with  under  these  conditions  may  be  most  difficult  to  arrest 
even  with  firmly  applied  sponges  on  holders,  the  slightest  trickling  of 
blood  beino-  sufficient  to  obscure  the  orifice  of  the  stricture.  A  false 
passage  at  the  site  of  the  stricture  may  complicate  matters  very  much, 
and  a  stricture  in  the  penile  portion  of  the  urethra  ma}"  prevent  the 
passage  of  the  staff  altogether.  A  good  light,  gentleness  and  patience 
are  at  all  times  requisite. 

Cock's  Operation. — An  external  urethrotomy,  which  opens  the 
urethra  behind  the  stricture,  and  without  a  guide  (Fig.  176).  The 
following,  in  the  words  of  its  deviser,  are  the  advantages  of  this 
operation  so  well  known  to  Guy's  men  [Gmfs  Hosp.  Reports,  1866, 
vol.  xii.  p.  267)  :    •■  The  bladder  is  reached  without  any  unnecessary 


Fig.  176. 


Mr.  Cock's  opeiation.     (Bryant. 


mutilation  of  the  perina^um.  The  communication  is  effected  in  nearly 
a  straight  line  from  the  exterior  to  the  cavit}'  of  the  viscus,  so  that  the 
cannula,  which  is  inserted  and  retained,  can  be  removed  whenever 
necessary,  and  can  be  easily  replaced.  The  functions  of  the  entire 
urethra  are  suspended,  and  may  be  kept  in  abe^-ance  for  an  unlimited 
period.  The  iirine  no  longer  finds  its  way  abnormally  through  the 
stricture  and  sinuses  of  the  perina?um.  The  tissues  are  no  longer 
subjected  to  constant  irritation  from  infiltration.  The  constitutional 
symptoms  are  relieved,  and  time  and  opportunit}"  are  given  for  the 
removal  by  absoi'ption  of  those  adventitious  products  which  obstructed 
the  urethra,  indurated  the  perina?um.  and  rendered  the  introduction  of 
an  instrument  impossible.  The  pressure  on  the  kidneys  is  removed, 
and,  if  expedient,  the  bladder  may  be  readih'  washed  out,  until  its 
lining  membrane  assumes  a  healthy  character.  The  strictured  and 
damaged  portion  of  the  urethra  being  no  longer  subjected  to  the 
constant  i:)ressure  of  ui"ine  from  behind,  may  probably  so  far  recover 


bleeding  is  going  on,  the  wountl  should  be  plugged  around  the  catheter  with  strips  of 
iodoform  or  sal-alenibroth  gauze,  or  Spencer  AVells's  forceps  left  in  situ. 


COCK'S  EXTERNAL  URETHROTOMY.  44 1 

itself  as  to  allow  of  restoration  by  the  ordinary  means  of  dilatation  ;  or, 
should  the  canal  have  become  permanently  obliterated,  the  patient  still 
retains  the  means  of  emptying  his  bladder  through  the  artificial 
opening  without  difficulty  or  distress,  and  at  very  moderate  incon- 
venience to  himself." 

The  following  are  the  case^  to  ichicU  the  operation  is  icell  suited  : 
Where  the  stricture  has  existed  for  a  number  of  years ;  where  the 
urethra  has  become  permanentl}^  obstructed  or  destro}-ed  by  the 
constant  pressure  of  urine  from  behind,  and  by  reiterated  attempts, 
generally  fruitless,  to  introduce  an  instrument ;  where  extravasation 
into  the  perinjeum  has  again  and  again  taken  place,  causing  repeated 
abscesses  and  their  consequences,  the  formation  of  urinary  sinuses  and 
fistulas,  until  the  normal  textures  of  the  perinteum  become  obliterated, 
and  are  replaced  by  an  indurated,  gristly  structure  ;  where  the  bladder 
has  become  thickened  and  contracted  hj  the  constant  action  of  its 
muscular  coat  until  little  or  no  cavit}'  is  left,  and  where  the  urine 
is  constantly  distilling  by  drops,  either  through  the  urethra  or  through 
one  or  several  fistulous  openings,  which  dot  the  surface  of  the  perina?um, 
penetrate  through  the  indurated  scrotum,  and  even  find  their  way  to 
the  nates  below,  and  the  region  of  the  pubes  above.  If  unrelieved, 
these  cases  invariably  terminate  fatally. 

The  Jceystone  of  the  tuhole  proceeding  is  the  fact  that,  "  however 
complicated  may  be  the  derangement  of  the  perina?um,  and  however 
extensive  the  obstruction  of  the  urethra,  one  portion  of  the  canal 
behind  the  stricture  is  always  healthy,  often  dilated,  and  accessible 
to  the  knife  of  the  surgeon.  I  mean  that  portion  of  the  urethra  which 
emerges  from  the  apex  of  the  prostate — a  part  which  is  never  the 
subject  of  stricture,  and  whose  exact  anatomical  position  may  be 
brought  under  the  recognition  of  the  finger  of  the  operator." 

Operation. — '-The  patient  is  to  be  placed  in  the  usual  position  for 
lithotomy ;  and  it  is  of  the  utmost  importance  that  the  body  and  pelvis 
should  be  straight,  so  that  the  median  line  may  be  accurately  preserved. 
The  left  forefinger  of  the  operator  is  then  introduced  into  the  rectum, 
the  bearings  of  the  prostate  are  next  examined  and  ascertained,  and  the 
tip  of  the  finger  is  lodged  at  the  apex  of  the  gland.  The  knife  is  then 
plunged  steadih^,  but  boldly,  into  the  median  line  of  the  perina?iim, 
and  carried  on  in  a  direction  towards  the  tip  of  the  left  forefinger, 
which  lies  in  the  rectum.  At  the  same  time,  by  an  upward  and  down- 
ward movement,  the  vertical  incision  maj'be  carried  in  the  median  line 
to  any  extent  that  is  considered  desirable.  The  lower  extremity  of  the 
woimd  should  come  to  within  half  an  inch  of  the  anus. 

"The  knife  should  never  be  withdrawn  in  its  progress  towards  the 
apex  of  the  prostate,  but  its  onward  course  must  be  steadily  maintained, 
until  its  point  can  be  felt  in  close  proximity  to  the  tip  of  the  left  fore- 
finger. When  the  operator  has  fully  assured  himself  as  to  the  relative 
position  of  his  finger,  the  apex  of  the  prostate,  and  the  point  of  his 
knife,  the  latter  is  to  be  advanced  with  a  section  somewhat  obliquely, 
either  to  the  right  or  the  left,  and  it  can  hardly  fail  to  pierce  the 
urethra.  If.  in  this  step  of  the  operation,  the  anterior  extremity  of  the 
prostate  should  be  somewhat  incised,  it  is  a  matter  of  no  consequence. 

"  In  this  operation  it  is  of  the  utmost  importance  that  the  knife  be 
not  removed  from  the  wound,  and  that  no  deviation  b*^  made  from  its 


442  OPERATIONS  OX  THE  ABDOMEN. 

original  direction  nntil  the  object  is  accomplished.  If  the  knife  be 
prematurely  removed,  it  will  probably,  when  re-inserted,  make  a  fresh 
incision  and  complicate  the  desired  result.  It  will  be  seen  that  the 
wound,  when  completed,  represents  a  triangle,  the  base  being  the 
external  vertical  incision  through  the  perinseum,  while  the  apex,  and 
consequently  the  point  of  the  knife,  impinges  on  the  prostate.  This 
shape  of  the  wound  facilitates  the  next  step  of  the  operation. 

••  The  knife  is  now  withdrawn,  but  the  left  forefinger  is  still  retained 
in  the  rectum.  The  probe-pointed  director  is  carried  through  the 
wound,  and,  guided  by  the  left  forefinger,  enters  the  urethra,  and  is 
passed  into  the  bladder.  A  No.  12  gum-elastic  catheter,  straightened 
on  its  stylet,  is  slid  along  the  director,  the  stylet  then  removed,  the 
catheter  cut  short,  and  secured  in  position  with  tapes." 

While  most  fully  alive  to  the  excellence  of  this  operation,  both  as  to 
speediness  of  relief  and  the  perfect  rest  it  gives  to  damaged  parts,  I 
should  like  to  point  out  to  those  who  are  only  likely  to  perform  it  occa- 
sionally, (a)  that  it  is  not  such  an  easy  operation  as  it  appears  ;  (/')  that 
it  is  a  severer  ojaeration  than  the  size  of  the  wound  would  suggest. 
Haemorrhage  is  not  very  uncommon  from  the  engorged  condition  of  the 
parts,  and  a  low  form  of  septic  phlebitis  is  not  very  infrequent  after 
the  operation.  For  these  reasons  I  would  restrict  it  to  the  cases  men- 
tioned at  p.  441. 

Complications  and  Causes  of  Failure  after  External  Urethrotomy. 

I.  Haemorrhage  (footnote,  p.  439).  2.  Eigors.  These  should  be  met 
by  warmth,  lea\dng  out  the  catheter  or  substituting  a  softer  one ;  plenty 
of  diluent  drinks,  washing  out  the  bladder  with  diluted  Thompson's 
fluid  (p.  401).  Dover's  powders,  or  small  injections  of  morphia,  if  the 
condition  of  the  kidney  admits  of  these.  Five  or  ten  grains  of  quinine 
may  be  given  in  milk  every  two  or  three  hours,  if  it  does  not  excite 
vomiting.  3.  Septic  troubles — e.^.,  septic  phlebitis.  4.  Pelviocellulitis. 
5 .  Persistence  of  a  fistulous  opening  in  the  perinseum.  6.  Recurrence 
of  the  contraction. 


CHOICE     OF     AN     OPERATION     FOR     THE      RELIEF      OF 
STRICTURE-RETENTION.* 

It  will  have  been  gathered  from  the  remarks  at  jd.  432  that  supra- 
pubic aspiration  -f-  may  be  used  in  very  urgent  cases,  and  may  be 
repeated  safely  once  where  this  fails.  In  many  cases  where  the  patient 
is  still  comparatively  young,  where  the  stricture  is  not  of  long  duration, 
where  there  are  no  urinary  fistulse  or  a  damaged  perinseum,  the  retention 
can  be  relieved  and  the  cure  of  the  stricture  started  by  forcible 
dilatation.  Ether  or  A.C.E.  having  been  given,  the  surgeon  takes  a 
silver  catheter  with  a  short  beak,  No.  4,  5,  or  6,  and  makes  forcible  steady 
pressure  against  the  face  of  the  stricture.  The  penis  should  be  kept 
stretched  by  an  assistant,  so  that  the  left  fingers  of  the  surgeon  are  free 
to  keep  note  of  the  middle  line.     After  a  few  minutes,  perhaps  aided  by 


*  Supra-pubic   tapping  has   been  already  recommended  for  retention  due    to  an 
tmlarged  prostate. 

f  lu  the  absence  of  an  aspirator,  an  ordinary  hydrocele  trocar  may  be  safely  used. 


INTERXAL  URETHROTOMY.  443 

a  smaller  size  of  catheter,  the  point  is  felt  to  pass  on,  in  the  middle  line, 
iciihoui  any  jumj),  and,  icithout  causimi  much  hieeding.  The  surgeon  is 
thus  sure  that  he  has  not  made  a  false  passage,  and  keeps  touch  of 
the  passage  of  the  catheter  down  the  centre  of  the  perinteum  with  his 
finger,  which  is  next  introduced  into  the  rectum.  Here  the  pulp  of  the 
finger  keeps  the  tip  of  the  catheter  a  little  up,  and  notices  carefully 
whether  the  instrument  is  in  the  middle  line  and  whether  it  is  separated 
from  the  finger  by  a  due  thickness  of  tissues.  If  these  points  are 
secured  and  the  point  of  the  catheter  moves  freely,  the  surgeon  may  be 
assured  that  he  has  reached  the  bladder.  I  have  used  this  method  of 
careful  forcible  dilatation  repeatedly,  and  think  most  highly  of  it. 

"Where  this  fails,  for  the  large  majority  of  cases  of  retention  due  to 
stricture,  especially  where  the  patient  is  under  45,  and  a  few 
days'  rest  will  ensure  the  passage  of  a  catheter,  I  believe  that  supra- 
pubic tapping  of  the  bladder  will  be  the  safest  and  simplest  operation. 
This  will  be  followed  in  four  or  five  days  by  the  passage  of  a  catheter, 
aided  by  an  anaesthetic,  and  guided  by  a  little  judicious  force,  combined 
with  a  knowledge  of  anatomy.  Wheelhoiise's  operation  is  very  highly 
spoken  of  by  the  Leeds  surgeons.  A  good  light  and  especial  instruments 
are  essential.  The  cases  to  which  Mr.  Cock's  excellent  operation 
should  be  limited  have  been  already*  pointed  out  (p.  441). 


INTERNAL    URETHROTOMY. 

Indications. — Before  specifying  these,  I  would  say  that,  with  regard 
to  the  question  between  external  and  internal  urethrotomy,  or  the  need 
of  either,  it  is  chiefl}'"  a  matter  of  personal  experience.  In  other  words, 
surgeons  who  practise  usually  some  such  operation  as  that  of  Prof. 
Syme,  and  I  confess  I  am  of  the  number,  when  careful  forcible  dilata- 
tion aided  by  an  anesthetic  fails,  will  probably  have  as  good  results  as 
those  who  resort  to  internal  urethrotomj-.  As  it  is  a  clean  division  of 
the  entire  stricture  which  is  required,  this  can  be  effected  most  readily, 
and  with  less  practice,  and  with  simpler  instruments,  by  external 
urethrotomy.  But  it  must  be  rememliered  that,  after  all,  it  is  not  so 
much  the  division  of  the  stricture,  whether  from  without  or  within, 
which  will  be  curative,  as  the  amount  of  perseverance  which  the  patient 
shows  afterwards.  Again,  at  the  commencement  of  internal  urethro- 
tomy, each  stricture  must  be  dilated  sufficiently  to  admit,  in  the  case  of 
an  instrument  cutting  from  without  inwards,  a  split  sound  equivalent 
to  No.  2  English,  while  in  instruments  cutting  in  the  opposite 
direction,  the  bulb  is  as  large  as  No.  4  or  5.  This  being  so.  the  cases 
must  be  very  few  in  which  the  surgeon  does  not  find  it  possible,  and 
in  which  the  patient  does  not  prefer,  to  complete  the  case  by 
dilatation. 

Amongst  these  few  cases  are — i.  Strictures  localised  and  of  the 
nature  of  annular,  which  (aj  contract  rapidly  after  dilatation,  or  (^)  in 
which  rigors  persistently  follow  attempts  at  dilatation.  2.  Xon- 
dilatable  strictures — e.g.,  some  traumatic  ones.  3.  Penile  strictures. 
These  are  very  elastic  and  shrink  quickl}^  after  dilatation,  and  incision 
of  these  strictures  seldom  causes  serious  constitutional  disturbance. 
4.  In  some  cases  where  time  is  an  object.     Thus,  in  young  subjects 


444  OPERATIONS  OX  THE  ABDOMEN. 

whose  disease  has  not  existed  long  enough  to  alter  the  condition  of  the 
kidneys,  cutting  may  be  admissible  for  a  stricture  that  should  be  simply 
dilated  in  an  older  patient  whose  kidneys  have  undergone  degeneration 
(Berkeley  Hill,  Did.  of  Simi.,  vol.  ii.  p.  727).  5.  According  to  some 
(Berkelej^  Hill,  loc.  supra  cit.),  urethrotomy  affords  a  longer  interval  of 
freedom  from  contraction  than  does  anj^  other  plan  of  widening  a 
stricture. 

Contra-indications. 

I.  Strictures  not  localised  and  ring-like,  biit  extending  over  a  con- 
siderable surface.  2.  A  '■stricture'*'  in  which  the  difficulty  is  mainly 
due  to  congestion,*  though  this  is  scarceh"  a  stricture  at  all.  3.  A 
stricture  accompanied  b}^  urethritis. 

I  have  endeavoured  to  point  out  fairly  the  indications  for  internal 
urethrotomy.  I  suspect  that  this  is  one  of  those  o]:»erations  of  which  an 
increasingly  frequent  use  is  liable  to  lead  to  something  very  like  abuse. 
But.  however  this  may  be.  I  should  like  to  point  out  first  a  fallacy  as  it 
seems  to  me.  Thus.  Sir  H.  Thompson  (Dis.  of  Urvn.  O'njans,  p.  40) 
speaks  of  a  urethrotome  as  "  nothing  more  than  a  little  knife  with 
a  long  blade  ....  used  precisely  as  we  use  a  scalpel  anywhere  else. 
Just  as  we  should  use  a  small  knife  in  tenotomy,  without  the  sense  of 
vision,  where  it  is  not  necessary,  but  guided  liy  the  sense  of  touch,  so  do 
I  advise  you  to  act  in  urethrotom}^"  No  doulot  this  comparison  is 
correct  as  far  as  it  goes,  liut  its  very  simplicity  is  misleading.  There 
can  be  no  real  comparison.  I  maintain,  between  division  of  a  tendon, 
which  can  always  be  practically  made  subcutaneous,  and  that  of  a 
stricture,  perhaps  four  inches  from  the  surface,  surrounded  by  vascular 
tissue,  incision  of  which  may  easily  lead  to  ha?morrhage  or  septic 
trouble,  an  incision  which  cannot  from  the  subsequent  flow  of  urine  be 
completed  aseptically,  and  which  implicates  other  parts  in  such 
intimate  sympathy  Avith  that  operated  on — e.g.,  the  kidneys. 

Again.  I  would  point  out  that  internal  urethrotomy  is  not  the  simple 
affair  that  it  is  sometimes  represented  to  be.  I  would  refer  my  readers 
to  the  experience  of  one  whose  name  is  associated  with  this  operation. 
Mr.  Berkeley  Hill  (Lancet,  April  8.  1876.  p.  524)  speaks  thus  of  a  trial 
which  he  gave  to  the  method  of  treating  early  stricture  by  Otis's 
operation  of  internal  urethrotomj' : 

'•  All  the  cases  operated  on  were  those  of  long-standing  gleets,  with 
contraction  in  one  or  more  parts  of  the  spongy  urethra,  and  had  under- 
gone multifarious  treatment.  The  number  of  patients  is  sixteen — 
fifteen  of  ni}'  own,  and  one  of  Dr.  Otis's.  In  five  cases  the  gleet  stopped 
after  the  operation,  and  the  patient  was  at  the  last  report — taken  in 
none  less  than  three  weeks,  in  most  some  months,  after  the  operation — 
able  to  pass  a  bougie  of  the  estimated  size  of  the  urethra.  In  short, 
they  may  be  claimed  as  cures.  But  of  these  five  the  operation  was 
serious  to  two ;  one  had  free  bleeding  for  three  days,  the  other  three 
attacks  of  rigors.  Of  the  remaining  eleven,  among  whom  Dr.  Otis's 
own  oi)eration  must  be  included,  the  gleet  persisted  in  all ;  in  several 
the  urethra  shrank  again  to  its  size  before  the  operation,  and  in  some 

*  As  bearing  upon  the  allied  condition  of  "  spasm,"  the  late  Mr.  B.  Hill  (Brit.  Med. 
Jonrn.,  1879,  vol.  ii.  p.  856)  stated  that  if  an  apparently  narrow  bulbo-membranous 
and  a  penile  stricture  co-exist,  on  the  latter  being  properly  divided,  the  former  will 
disappear,  having  been  due  to  reflex  muscular  contraction. 


INTERNAL   URETIIIUJTOMY.  445 

very  serious  complications  ensued.  In  four,  bleeding  lasted  several 
daj'S  and  in  one  was  alarming.  Three  patients  had  rigors  ;  in  two  the 
shivering  Avas  unimportant,  being  that  which  follows  the  first  transit  of 
urine  along  the  incised  urethra  in  certain  individuals,  but  is  not 
repeated  or  attended  bj^  further  consequences.  In  the  third  patient 
the  rigors  preceded  abscess  in  the  buttock.  One  patient  had  orchitis. 
Thus,  in  seven  the  operation  might  fairly  be  termed  a  trifle,  causing  no 
pain  nor  any  after-fever,  but  in  five  only  was  the  operation  successful." 

Complications. — (i)  Haemorrhage.  If  severe  this  may  be  met  by 
pressure  on  the  perinasum,  with  a  pad  or  a  stick  in  the  bed  so  that  the 
patient  ma}^  keep  up  the  compression  himself.  (2)  Perinaeal  abscess. 
("3)  Sloughing  and  perinteal  fistula.  These  are  very  rare.  (4)  Extra- 
vasation. (5)  Septicajmia.  (6)  Epididymitis.  The  first  five  of  these 
are  usually  due  to  cutting  too  deeply,  or  to  the  patient  not  being 
sufficiently  prepared  or  unfit  for  the  operation.  The  last  is  usually 
brought  about  by  injudicious  haste  in  the  use  of  bougies. 

The  essentials  of  a  ijood  xirethrotome  are  :  ( i )  a  guide  through  the 
stricture  into  the  bladder,  usually  in  the  form  of  a  filiform  guide-bougie, 
or  of  a  curved  terminal  portion  of  the  urethrotome,  sufficiently  fine  to 
pass  through  the  narrowest  stricture ;  (2)  a  cutting  edge  which,  at 
first  shielded,  can  be  protruded  by  the  surgeon  as  exactly  as  he  desires ; 
(3)  some  means  of  steadying  the  mobile  stricture  fibres  as  they  are 
divided. 

Two  Chief  Modes  of  Internal  Urethrotomy. — The  stricture  may  be 
divided — {a)  From  without  inwards — i.e..  towards  the  bladder. 
(/>)  From  within  outwards,  away  from  the  bladder.  A  short  account 
of  the  chief  instruments  will  be  given,  and  the  two  methods  briefly 
contrasted. 

a.  Those  Cutting  from  Without  Inwards. — By  this  means  narrower 
strictures  can  be  divided  than  in  the  other  method,  in  which  the 
instruments  used  are  generally  based  on  Civiale's  pattern,  in  which 
the  bulbous  end  carries  the  knife. 

Most  of  the  urethrotomes  which  cut  from  without  inwards  are 
modifications  of  Maisonneuve's  pattern.  A  fine  hollow  staff  being- 
guided  through  the  stricture  by  a  filiform  bougie,  along  the  hollow 
staff  a  stylet  carrying  a  triangular  shield  or  wedge  is  run ;  this  pushed 
against  the  stricture  serves  to  steady  it.  while  it  is  divided  by  a  knife 
concealed  in  the  wedge  or  shield. 

One  of  the  best  known  of  the  recent  instruments  on  this  pattei'n  is 
the  late  Mr.  B.  IlilFs.  It  consists  of  a  narrow  split  sound,  No.  2 
English,  which  can  be  guided  through  narrow  tortuous  strictures  by 
being  attached  to  a  filiform  bougie,  previously  passed  into  the  bladder.* 
Secondly,  a  wedge  runs  along  dovetail  grooves  between  the  halves 
of  the  split  sound.  In  this  wedge  is  concealed  a  knife  that  can  be 
protruded  between  the  halves  of  the  split  sound,  when  the  stricture- 
tissue  prevents  their  separation  sufficiently  to  allow  the  wedge  to  pass 
on.     The  wedge, f  pushed  up  to  the  situation  of  the  stricture,  in  separat- 

*  If  it  is  doubtful  whether  the  guide  has  reached  the  bladder,  Mr.  Hill  advised  to 
screw  on  a  No.  i  flexible  catheter  to  the  guide,  and  to  push  the  whole  onwards  till  the 
catheter  has  passed  eight  inches  inwards.  A  small  exhausting  syringe  is  then  applied 
to  the  catlieter,  and  a  few  drops  of  urine  drawn  throiigh  it. 

f  The  meatus  must  be  divided,  if  too  small  to  admit  the  wedire-. 


446  OPEEATIOXS  ON   THE  ABDOMEX. 

ing  the  split  sound  tightens  and  steadies  the  stricture  thoroughly, 
while  the  knife  divides  it  to  the  width  required  by  the  wedge  to  pass 
along.*  If  a  wedge  be  chosen  to  expand  the  urethra  to  its  fiill  natural 
capacity,  the  cut  will  not  pass  beyond  the  stricture  into  the  vascular 
erectile  tissue  external  to  it.  The  knife  can  be  applied  to  the  upper  or 
under  surface  of  the  stricture  as  preferred. 

h.  Those  Cutting  from  Within  Outwards. — A  good  representative 
of  these  instruments  is  Sir  H.  Thompson's  modification  of  Civiale's 
urethrotome.  This  has  a  bulbous  extremity,  from  which  the  blade  is 
protruded.  The  stricture  being  sufficiently  dilated  to  admit  a  Xo.  4  or 
5  bougie,  the  bulb  (which  forms  a  useful  sound)  is  carried  about  one- 
third  of  an  inch  beyond  the  stricture,  the  knife  projected,  and  the  incision 
made  by  dra^^ing  it  slowly  and  firmly  outwards — to  the  distance  of 
half  an  inch  to  two  inches — generally  along  the  floor  of  the  urethra, 
so  as  to  incise  the  stricture  freely.  A  metallic  bougie  is  then  passed, 
and  if  at  any  point  it  is  held  closely,  there  is  still  almost  certainly 
some  spot  which  needs  touching  with  the  blade. 

After-treatment. — This  varies  very  much.  Some  surgeons — e.<j.,  Sir 
H.  Thompson  and  Mr.  Harrison — pass  at  once  and  tie  in  a  full-sized 
catheter  for  twenty-four  or  forty-eight  hours,  passing  after  this  a  full- 
sized  instrument  at  intervals.  Others — e.g.,  Mr.  B.  Hill — draw  off  the 
urine  with  a  full-sized  catheter,  after  division  of  the  stricture,  but  tie 
none  in.  The  patient  is  ordered  not  to  micturate  for  eight  hours  if 
possible.  By  this  time  the  incision  is  protected  by  clot  and  plastic 
lymph,  and  when  the  bladder  must  be  emptied,  the  patient  passes 
\\ater  in  a  hot  bath,  pain,  spasm,  and  risk  of  tearing  open  the  wound 
l)eing  thus  avoided.  The  patient  is  kept  in  bed  for  ten  days,  and 
aV)out  the  eighth  day  a  full-sized  bougie  is  passed,  this  period  of  rest 
being  insisted  upon  to  avoid  pain,  bleeding,  and  suppuration. 

Comparison  of  the  two  Methods  of  Internal  Urethrotomy. — 
With  the  instruments  which  cut  from  without  inwards,  guided  by  a 
filifonn  bougie,  narrower  strictures  can  be  attacked  than  by  the  bulbous- 
ended  urethrotome,  cutting  in  the  reverse  direction.  These  latter  have 
been  i-ecommended  as  having  the  advantage  of  steadying  the  fibres  to  be 
cut  by  their  j^ulling  forwards  the  paints  which  attach  the  urethra  to 
the  pelvis  as  the  bulbous  end  of  the  instrument  is  drawn  out.  The 
stricture  is  thus  pulled  on  by  the  instrument  until  the  divided  sti-icture 
gives  free  passage  to  the  bulbous  shield  and  the  knife  protruded  from 
it.  Mr.  B.  Hill,  however,  considered  that  "  reliance  cannot  be  placed  on 
the  simple  straining  of  these  attachments  ensuring  perfect  division  of 
the  stricture  tissue.  A  Civiale's  or  any  other  urethrotome  which  cuts 
from  within  outwards  is  very  apt  to  wriggle  its  way  through  a  stricture, 
only  scoring  it,  but  not  perfectly  severing  its  fibres,  and  to  meet  this 
difficulty  the  knife  is  often  carried  more  deeply  than  is  necessary."  Mr. 
Hill  further  believes  that  by  cutting  from  without  inwards  there  is  less 
risk  "  of  making  an  incision  through  a  thin  layer  of  fibrous  tissue  into 
erectile  tissue,  in  the  belief  that  a  thick  layer  of  fibrous  tissue  exists," 
and  thus  of  causing  free  heemorrhage. 

While  myself  usually  practising  what,  on  the  whole,  I  believe  to  be 

*  After  the  first  cut,  the  knife  is  withdrawn  Avithin  the  wedge,  and  only  protruded 
when  a  tight  baud  opposes  the  free  passage  of  the  wedge. 


ECTOPIA   VESICAE  AXU  EPISPADIAS.  447 

preferable,  continuous  dilatation  aided,  if  need  be,  by  external  urethro- 
toniT  such  as  Prof.  Syme's  o})eration,  I  have.  I  trust,  here  fairly  dealt 
with  internal  urethrotomy.  Before  leaving  this  matter  I  should  like  to 
allude  to  the  question  of  time.  Internal  urethrotomy  no  doubt  saves 
time  and  trouble  also,  but  it  must  not  be  thought  that  the  saving  is  a 
large  one.  Thus,  with  regard  to  time,  Mr.  B.  Hill  wrote:  *  "  It  is  indis- 
pensable that  the  patient  lie  in  bed  continuously  for  at  least  ten  days, 
and  keep  his  room  for  fourteen  daj's."  Subsequent  regular  passage 
of  a  bougie  is  as  needful  after  internal  urethrotomy  as  smy  other  mode 
of  treatino-  stricture. 


ECTOPIA  VESICA  AND  EPISPADIAS. 

The  various  plans  that  have  been  devised  for  the  relief  of  this  most 
miserable  condition  may  practically  be  divided  into  two  groups.  The 
Jirst  group  consists  of  plastic  operations,  which  aim  at  the  formation  of 
a  new  anterior  vesical  wall  and  urethra.  Those  methods  associated  with 
the  names  of  Wood  and  JMaydl  have  been  most  Avidely  adopted.  As  will 
be  seen  b}'  reference  to  the  description  given  below,  the  anterior  wall  of 
the  bladder  is  formed  by  skin-flaps.  The  advantages  gained  b}'  the 
operation,  if  successful,  are  that  a  receptacle  for  the  urine  is  formed, 
and  that  the  exposed  mucous  membrane  is  covered  in.  On  the  other 
hand,  there  is  no  sphincter,  therefore  no  control,  and  a  urinal  must  be 
worn  constantly  as  before.  Moreover,  with  the  growth  of  hair  into 
the  bladder  cystitis  is  set  up  and  the  hairs  are  constantly  the  seat  of 
phosphatic  deposit  which  will  j)robably  have  to  be  removed  at  intervals. 

Attempts  have,  however,  been  recenth^  made  to  form  the  new  bladder 
of  mucous  membrane  instead  of  skin.  Tizzoni  and  Poggi  successfully 
removed  the  bladder  of  a  dog  and  replaced  it  by  a  new  bladder  formed 
from  a  piece  of  small  intestine,  which  they  left  attached  to  its  mesentery 
after  having  cut  it  out  of  the  circuit  of  the  alimentary  canal.  Rut- 
kowski  (Centr.  fiir  Chir.,  No.  16.  1899),  acting  on  this  suggestion, 
successfully  made  use  of  an  intestinal  flap  for  ectopia  in  a  boy  aged  9. 

The  following  account  of  the  operation  is  given  by  Warbasse  (Ann. 
of  Surg.,  Aug.,  1899) : 

A  median  incision,  ^^ix  centimetres  long,  was  made,  terminating  below  at  the 
bladder.  After  opening  the  abdomen,  a  coil  of  ileum  was  brought  out  and  divided  at 
two  points,  six  centimetres  apart.  This  six  centimetres  of  intestine  was  isolated. 
The  intestine  was  united  by  an  end-to-end  anastomosis  with  two  rows  of  continuous  silk 
suture,  and  replaced  in  the  abdomen.  The  excised  segment  was  divided  longitudinally 
opposite  its  mesentery,  thus  forming  a  quadrilateral  flap  about  forty  square  centimetres 
in  size,  attached  to  the  mesentery  along  its  middle.  After  detaching  the  bladder  from 
the  abdominal  wall  and  enlarging  the  bladder  opening,  the  intestinal  flap  was  sutured 
by  two  rows  of  running  suture  into  the  defect.  The  deeper  suture  of  catgut  included  the 
entire  thickness  of  the  bladder  and  intestinal  walls,  with  the  exception  of  the  mucosa. 
The  outer  suture  of  silk  was  applied  as  a  Lembert  suture.  This  gave  a  urinary  bladder 
with  an  anterior  wall  formed  from  intestinal  flap  receiving  its  nourishment  through 
its  own  segment  of  mesentery.     Over  the  whole  the  abdominal  wall  was  closed.     A 


*  Diet,  of  Surg.,  vol.  ii.  p.  729.     See  also  the  Lectures,  alike  candid  and  helpful  in 
detail,  by  the  same  surgeon  (^Brit.  Med.  Joum.  1879,  vol.  ii.  pp.  763  et  .vry.) 


448  OPEKATIUXS  ON  THE  ABDOMEN. 

catheter  was  left  in  the  urethra  for  permanent  drainage  of  the  bladder.  The  ope- 
ration lasted  an  hour  and  a-half.  The  condition  of  the  patient  immediately  after  the 
operation  was  excellent.  The  post-operative  course  of  the  case  was  ideal,  entirely 
afebrile.  The  wound  healed  per  primane.  On  the  tenth  day  the  sutures  were  removed. 
Eight  weeks  after  the  operation  the  patient  was  able  to  retain  twenty-five  cubic  centi- 
metres of  urine  in  the  bladder.  Under  pressure  this  amount  could  be  increased  to 
thirty  cubic  centimetres." 

In  the  second  ffroup  of  operations  no  attempt  is  made  to  form  a 
bladder,  but  the  course  of  the  urine  is  diverted  into  the  bowel,  which 
thus  becomes  the  receptacle  for  the  urine. 

A-  number  of  surgeons  have  excised  the  vesical  mucous  membrane  and 
implanted  the  ureters  in  the  rectum  or  sigmoid.  The  chief  objection  to 
this  is  the  liability  to  infection  of  the  ureters  from  the  bowel,  resulting- 
in  ascending  nephritis.  Maydl  has,  however,  largely  overcome  the  risk 
of  infection  by  implanting  the  whole  trigone  into  the  rectum,  thus 
retaining  the  valvular  orifices  of  the  ureters.  Brandsford  Lewis  {Ann. 
of  Surg.,  June,  1900),  in  a  review  of  this  subject,  quotes  a  number  of 
cases  operated  on  by  ]\raydrs  method.  The  following  case,  operated 
upon  by  Dr.  Herezel,  of  Budapest,  will  serve  to  illustrate  what  may  be 
hoped  for  as  a  result  of  this  operation  : 

••  A  boy,  5  years  old,  was  operated  on  in  May,  1897.  In  March,  1898,  his  condition 
was  reported  by  the  operator  as  admirable.  Quantity  of  urine  1000 — 1200  cubic  centi- 
metres in  twenty-four  hours;  specific  gravity  1013 ;  slight  amount  of  albumen,  no 
pus.  The  boy  was  able  to  hold  the  urine  five  hours  at  a  time,  and  then  to  eject  it 
in  a  good  stream  from  the  rectum.  In  August,  1899  (a  year  and  a-half  after  the  opera- 
tion) the  condition  continued  as  satisfactory.  The  patient,  now  a  rapidly  growing 
and  strengthening  boy,  enjoyed  living,  retaining  his  urine  for  six  or  seven  hours  during 
the  day-time,  but  relieving  himself  oftener  at  night,  or  running  the  risk  of  wetting 
the  bed  while  in  deep  sleep." 

The  same  author  also  quotes  the  results  of  seventeen  operations  by 
Maydl's  method,  collected  by  Nove- Josserand.  There  were  two  deaths 
— one  from  shock,  and  the  other  from  infection.  "  The  secondary 
accidents  noted  were  fistulas  of  the  urinary  passages  with  an  accom- 
panying localised  peritonitis,  all  of  which  cases  recovered.  Pyelo- 
nephritis, as  the  result  of  ascending  infection,  resulted  in  the  death 
of  one  case  after  a  period  of  four  months.  Urinary  continence  was 
perfect  in  all  the  cases  excepting  two.  The  patients  were  able  to  hold 
their  urine  for  at  least  three  hours,  sometimes  six  or  seven  hours,  and 
in  one  case  throughout  the  night.  The  urine  was  voided  sometimes 
mixed  with  faecal  matter,  sometimes  alone.  The  tolerance  of  the  rectal 
membrane  was  perfect." 

In  spite  of  the  fact  that  this  operation  is  undoubtedly  far  more 
severe  than  the  plastic  method,  the  immediate  results  are  extremely 
good,  and  far  better  than  those  of  the  older  methods.  Time  alone 
can  settle  the  question  as  to  whether  destruction  of  the  kidneys 
from  ascending  inflammation  will  be  a  more  common  late  result  than 
after  a  plastic  operation. 

Operations. — Two  will  be  described:  (i)  Wood's  plastic  method; 
(2)  Cysto-colostomy,  or  Ma^'dl's  operation. 

(l)  Wood's  Operation. 

j[ge_ — The  cure  of  the  ectopia  may  be  commenced  after  the  child  is 
four  or  five,  and  should  be  completed,  if  possible,  by  puberty.     In  this 


ECTOPIA  VESICAE   AND  EPISPADIAS.  449 

case  the  epispadias  may  be  taken  in  hand  and  completed  before  ado- 
lescence, when  the  growth  of  hairs  and  sexual  desires  will  interfere 
much  with  the  union  of  the  flaps. 

Unfavourable  (Joaditlons* — i.  Large  size  of  the  ectopia,  with  much 
bleeding  and  some  puru.lent  discharge  from  the  surface.  2.  A  sickly- 
condition  of  the  patient,  pointing  to  poor  powers  of  repair,  and  a 
waddling  gait  to  wide  separation  of  the  pubes.  3.  Tendency  to  cough. 
This  increases  the  protrusion.  4.  Presence  of  large  herniaj.  5.  Secon- 
dary dilatation  of  the  ureters  and  pelves  of  the  kidneys,  with  degen- 
eration of  viscera.  Mr.  Wood  (loc.  siipxc  cit.)  shows  that  sometimes 
the  above  complication  may  be  recognised  by  the  presence  of  more 
albuminuria  than  is  accounted  for  by  the  amount  of  cj'stitis.  In  other 
cases  no  such  signs  are  present.  Out  of  forty  cases,  a  fatal  result, 
chiefly  from  this  cause  and  undetected,  followed  in  four.  6.  Obstinate 
eczematous  rawness.     7.  Small  size  of  the  scrotum.     This  is  rare. 

Preparatory  Treatment. — If  the  patient  has  passed  pubert}^,  and  the 
hair  is  at  all  abundant,  depilation  should  be  practised,  and  nitric  acid 
applied  at  intervals  to  the  groups  of  hair-follicles. 

It  may  be  well  also  to  try  and  diminish  the  size  of  the  ectopia  by  the 
means  adopted  by  the  late  ]Mr.  Greig  Smith,  who,  for  some  weeks  pre- 
vious to  operation,  kept  the  patient  on  his  back,  and  the  exposed  mucous 
membrane  shielded  with  green  "•protective"  coated  with  dextrine, 
covering  this  over  with  boracic  lint,  and  by  this  means,  in  one  case,  the 
mucous  membrane  not  only  became  less  angiy,  but  its  upper  half,  almost 
as  lo\\'  as  the  ureters,  became  covered  with  epidermis  almost  as  white  as 
the  surrounding  skin.  In  another  case,  also  successfully  operated  on, 
no  preliminary  treatment  was  of  any  avail  in  diminishing  the  size  of 
the  ectopia. 

Operation. — An  angesthetic  having  been  given,  a  median  flap-j-  is 
raised  from  the  abdominal  wall  above  the  exposed  bladder.  Its  shape 
resembles  that  of  the  wooden  portion  of  a  fire-bellows,  its  length  is 
rather  greater  than  the  distance  between  the  root  of  the  penis  and  the 
upper  margin  of  the  exjDosed  bladder,  \\hile  its  root  must  be  sufiiciently 
broad  to  ensure  a  sufficient  blood-supph'.  In  raising  it,  care  must  be 
taken  not  to  cut  it  too  thin,  and,  at  the  same  time,  not  to  go  too  deeply 
with  the  point  of  the  knife,  as  the  tissues  here  are  extremely  thin, 
and  the  flat,  tense,  expanded  linea  alba  beneath  is  often  very  thin,  and 
thus  the  peritonasal  sac  may  easily"  be  opened. 

The  two  groin  flaps  are  next  made,  of  rounded  oval  shape,  with  broad 
pedicles,  the  outer  boundarj-  of  which  is  sufficiently  carried  out  on  to 
the  thigh,  and  then  on  to  the  root  of  the  scrotum,  to  ensure  its  contain- 
ing the  superficial  epigastric  and  the  external  pudic  arteries.  The 
inner  margins  of  these  flaps  join  those  for  the  central  flap  at  about  its 


*  For  full  informatiou  ou  all  these  matters  Mr.  J.  Wood's  articles  (^Dict.  of  Surg.. 
vol.  i.  p.  425,  and  Mcd.-Chir.  Trans.,  vol.  iii.  p.  85)  should  be  consulted. 

t  The  shape  and  arrangement  of  the  flaps  are  excellently  shown  in  pi.  ii..  figs,  i  and  2, 
accompanying  Mr.  Wood's  paper  (JSIvil.-Cldr.  Trans,,  vol.  Iii).  Some  illustrations  of  other 
flaps  in  a  paper  by  Mr.  Mayo  Robson  (^Brit.  Med.  Journ.,  1885,  vol.  i.  p.  222)  will  also 
be  found  useful.  And  I  would  direct  my  readers'  attention  to  a  paper  by  the  late 
Mr.  W.  Anderson  (CZm.  Soc.  Trans.,  vol.  xxv.  p.  78),  which  contains,  as  might  be 
expected,  some  very  helpful  drawings. 

VOL.    II.  29 


450  OPERATIONS  ON  THE  ABDOMEX. 

centre,   and   are  then   continued  down  along  the  side  of   the  urethral 
groove  for  about  half  its  length. 

While  these  flaps  must  be  cut  as  thick  as  possible,  care  must  be  taken 
to  avoid  am^  subsequent  hernia,  and  they  must  be  sufiiciently  detached 
to  meet  for  their  whole  length,  without  tension,  in  the  middle  line.  In 
raising  them  they  must  be  handled  as  carefully  as  possible,  whether  with 
fingers  or  with  bluntly  serrated  forceps,  so  as  in  no  way  to  impair  their 
vitality.  All  bleeding  having  been  stopped,  the  flaps  washed  with 
boracic-acid  lotion,  and  their  surfaces  allowed  to  become  glazed,*  the 
umbilical  flap  is  first  taken  and  folded  down,  with  its  skin  surface  towards 
the  bladder,  evenly  and  without  tension.  It  is  then  stitched  to  the  cut 
edge  at  the  root  of  the  penis. 

The  groin  flaps  are  then  drawn  inwards,  placed  with  their  raw 
surfaces  upon  the  raw  surface  of  the  umbilical  flap,  and  carefully 
stitched  together.  The  sutures  should  be  many  and  mixed,  of  wire, 
carbolised  silk,  fishing-gut,  and  horsehair.  Wire  has  the  advantage  of 
being  non-irritating  and  of  keeping  sweet  in  a  wound  which  cannot  be 
kept  aseptic.  The  sutures  should  be  left  in  for  a  fortnight,  and,  in  the 
case  of  children,  it  may  be  well  to  give  an  anesthetic  to  take  them  out. 

The  raw  surface  from  which  the  central  flap  was  taken  is  then  closed, 
as  far  as  possible,  with  long  hare-lip  pins  and  twisted  sutures.  The 
rest  of  this  wound  may  be  closed,  now  or  later  on,  by  Thiersch's  method 
of  skin-grafting  (Vol.  i.  p.  i88). 

The  parts  are  then  painted  with  collodion  and  iodoform,  sal-alembroth 
gauze  applied,  and  the  buttocks  and  hips  smeared  with  eucalyptus 
and  vaseline.  If  any  redness  appear,  wet  boracic-acid  lint  dressings 
should  be  made  use  of. 

Prof.  Trendelenberg  (Centr.  f.  Chir.,  No.  49,  Dec.  1885)  published  a 
case  of  extroversion  of  the  bladder  in  which  immediate  union  of  the 
lateral  margins  was  obtained  by  previous  division  of  the  sacro-iliac 
synchondroses.  By  entirely  freeing  the  joints  and  breaking  their  sides 
free  this  surgeon  has  gained  an  approximation  between  the  anterior 
superior  spines  of  two  inches  in  a  child  of  two  and  a-half.  This 
approximation  is  of  course  only  rendered  possible  by  the  fact  that  the 
symphysis  pubis  is  deficient  in  these  cases.  When  the  bones  are  thus 
approximated  the  lateral  margins  of  the  defect  are  pared,  and  brought 
together  with  sutures.  This,  when  successful,  effects  a  great  saving  of 
time,  and  secures  that  the  cavity  of  the  bladder  shall  consist,  save  for 
a  narrow  line  of  scar"  in  front,  of  vesical  mucous  membrane  and  not 
of  scar-tissue.  As  a  result  the  formation  of  phosphatic  deposit  is 
greatlj^  diminished.  A  veiy  interesting  account  of  this  operation 
has  been  given  by  Mr.  Makins  with  a  successful  case  (Trans.  Med- 
Chir.  Soc,  vol.  Ixxi.  p.  191).  To  be  successful  the  division  of  the  syn- 
chondroses shoiild  be  performed  early,  e.g.,  before  the  child  is  five. 

After-treatment. — The  patient  must  be  kept  partly  sitting,  the 
shoulders  being  \ve\\  propped  up  and  the  knees  flexed  ;  a  bandage  passed 
from  the  knees  around  the  shoulders  will  facilitate  this.  Any  sudden 
straightening  of  himself  by  the  patient  is  fatal  to  a  good  result.     For 

*  Spencer  Wells's  forceps  should  be  left  for  five  or  ten  minutes  on  any  bleeding 
points,  and  all  ligfatures,  even  of  fine  chromic  gut,  dispensed  with,  if  possible.  Oozing 
will  yield  to  firm  sponge-pressure. 


HYPOSPADIAS.  45 1 

the  first  few  days  small  opiates  or  injections  of  morphia  will  be 
required. 

(2)  Cysto-Colostomy  (Maydl's  Operation).  —  The  abdomen  is 
opened  by  a  vertical  incision  running  down  to  the  mucous  membrane 
of  the  bladder.  The  area  of  the  latter,  including  the  trigone,  is  then 
carefully  dissected  up  and  separated  from  the  rest  of  the  bladder  and 
commencement  of  the  urethra. 

A  loop  of  sigmoid  is  now  drawn  through  the  wound,  and  the 
abdominal  cavity  protected  by  gauze  packing.  A  longitudinal  incision 
of  the  required  length  is  uext  made  in  the  right  side  of  the  exposed 
loop  of  sigmoid,  escape  of  contents  being  prevented,  if  necessary,  by 
the  application  of  clamps.  The  trigone  is  now  rotated  through  about 
ninety  degrees,  so  that  the  ureters  now  lie  above  one  another  instead  of 
side  by  side,  and  is  attached  to  the  margins  of  the  opening  in  the  sigmoid 
by  means  of  sutures.  Two  rows  of  sutures  are  required,  a  deeper  one 
uniting  the  mucous  membrane  of  bladder  and  sigmoid,  and  a  super- 
ficial row  of  Lembert's  sutures  passing  through  the  muscular  wall  of  the 
bladder  and  serous  and  muscular  coats  of  the  sigmoid. 

Any  remaining  bladder  mucous  membrane  having  been  excised,  the 
loop  of  sigmoid  is  now  dropped  back  into  the  abdomen.  A  tampon  of 
iodoform  gauze  is  then  passed  down  to  the  site  of  the  anastomosis  to 
provide  against  possible  leakage,  and  the  rest  of  the  wound  closed. 


HYPOSPADIAS. 

Varieties. — These  are  three,  viz.:  i.  Glandular. — The  opening  is 
here  merely  farther  back  than  usual,  the  fraenum  is  absent,  the  glans 
broad,  flattened,  somewhat  recurved,  and  the  prepuce,  often  hood-like, 
always  in  a  condition  of  partial  paraphimosis.  2.  Penile. — Here  the 
urethra  is  especially  liable  to  open  at  one  of  the  three  following  sites  : 
(a)  Just  behind  the  glans ;  (h)  at  the  middle  of  the  penis ;  (c)  at  the 
jvmction  of  the  penis  and  scrotum.  3.  Scrotal.* — Here  the  cleft  on 
which  the  urethra  opens  may  be  either  at  the  junction  of  the  penis  and 
scrotum,  or  involve  the  scrotum  and  peringeum,  the  former  being  called 
peno-scrotal,  and  the  latter  perinEeo-scrotal. 

When  an  operation  is  under  consideration,  with  a  view  of  rendering- 
micturition  and  coitus  normal,  the  surgeon  must  take  into  due  considera- 
tion— (a)  the  degree  of  the  deformity;  (/3)  whether  the  penis  is  fairly  de- 
veloped ;  (7)  whether  it  is  much  tied  down ;  (8)  whether  the  testicles 
are  present  and  descended  ;  (e)  how  far  the  patient's  condition  is  made 
miserable  by  rawness  and  eczema  due  to  impeded  micturition,  and  by 
impeded  coitvis  ;  and  how  far  there  are  reasonable  hopes  of  remedying 
these.     Two  methods  of  operating  will  be  described. 

I.  Duplay's  Operation. — The  operation  is  divided  into  the  follow- 
ing three  stages,  which  require,  in  order  to  be  successful,  much  time 
and  patience  on  the  part  of  both  surgeon  and  patient : 

i.  Straightening  the  penis  and  formation  of  a  meatus ;  ii.  Formation  0/ 


The  above  is  sometimes  divided  into  two — scrotal  and  periuaeo-scrotaL 


452 


OPERATIONS   OX  THE  ABDOMEN. 


Fig.   177. 


a  canal  fro')n  the  meatus  to  the  Jii/posjiadiac  openimj  ;   iii.  Junction  of  the 
old  and  n&w  canal. 

i.  8trai(ihtening  of  the  Penis. — In  the  penile,  peno-,  and  perinseo- 
scrotal  varieties,  the  penis,  often  short,  is  recurved,*  especial!}'  during 
erection,  by  a  band  consisting  partly  of  a  muco-cutaneous  ridge, 
corresponding  to  the  absent  urethra,  and  reaching  from  the  hypo- 
spadiac  orifice  to  the  glans.  M.  Bouisson  seems  to  have  first  pointed 
out  the  importance  of  dividing  this,  which  he  did  subcutaneously. 
M.   Dupla}^  recommends    division   b}'    an    open    wound,    carrying   the 

incision  as  deeply  as  needful,  and  states 
that  the  corpora  cavernosa  may  be  incised 
to  a  very  considerable  depth,  if  needful  to 
secure  this  end.  M.  Du.play's  incision  leaves 
a  lozenge-shaped  \\ound,  which  he  unites  by 
sutures  (Fig.  177.  B  and  C). 

At  the  same  time  the  above-named  sur- 
geon forms  a  meatus.  This  is  done  by 
paring  the  two  lips  of  the  depression  which 
represents  the  meatus,  and  uniting  these 
over  a  bit  of  catheter.  If  the  depression 
be  very  shallow,  an  incision  upward  into 
the  glans-tissue,  or  two  lateral  ones,  may 
be  needed  before  it  is  possible  to  insert  a 
catheter,  and  to  appl}^  sutures  round  it. 

ii.  Formation  of  a  Nerr  Urefhra.'\ — The 
penis  being  held  up,  two  incisions  are  made 
a  little  outside  the  lateral  margins  of  the 
mucous  surface  corresponding  to  the  de- 
ficient urethra,  and  reaching  from  the  glans 
to  the  hypospadiac  orifice.  By  making  two 
transverse  incisions  at  either  end,  two  narrow  quadrilateral  flaps.  a,h,a',h' 
(Fig.  177  D),  are  dissected  up  towards  the  middle  line  until,  with  their 
mucous  surfaces  turned  inwards  and  their  raw  surfaces  out^'ards,  they 
meet  without  tension  over,  and  thus  shut  in  a  catheter  passed  from 
the  previous!}^  restored  meatus  to  the  hypospadiac  orifice.  These  flaps 
are  now  united  with  sutures,  partly  of  fine  chromic  gut  and  partly  of 
fine  carbolised  silk,  cut  quite  short.  From  the  sides  of  the  penis  two 
similar  flaps,  c,  d,  c  d!  (Fig.  177  D),  are  dissected  up  from  within  out- 
Avards,  till  they  can  be  sufficiently  drawn  inwards  without  tension  to 
cover  over  the  raw  surfaces  of  the  internal  flaps.  They  are  then  care- 
full}^  united  in  the  middle  line  (Fig.  177  E).  I  much  prefer  horsehair 
and  fishing-gut  sutures  here,  well  soaked  previously  in  warm  carbolic 
acid. 

In  operating  upon  boys,  and  I  consider  nine  to  fifteen  as  the  best  age, 
I  prefer,  in  penile  hypospadias,  to  make  the  new  glans  and  restore  the 
floor  of  the  urethra  at  one  sitting.  Any  points  where  union  fails  can 
be  closed  later.     The  chief  trouble  is  the  retention  of  the  catheter  suffi- 


(Bryant. 


*  This  recurving  is  also  in  part  due  to  thickening  and  shortening  of  the  capsule  of 
the  corpora  cavernosa,  and  even  of  the  septum. 

t  Several  months,  at  least  five  or  six,  must  elapse  before  the  surgeon  is  certain  that 
no  recurving  will  occur.     This  disappears  very  gradually. 


HYPOSPADIAS.  453 

ciently  long.  I  have  usually  found  that  after  the  third  day  the  delicate 
mucous  membrane  of  a  child's  bladder  resents  the  cathetei' — a  very  little 
mucus  quickly  plugs  these  small  instruments — and  a  nurse  must  be 
instructed  to  pass  a  small  india-rubber  catheter  every  two  or  three 
hours.  In  the  intervals  a  short  bit  of  bougie  is  kept  in  the  new  urethra 
and  glans  to  maintain  the  patency  of  the  canal.  Iodoform  and  collodion 
with  a  dry  dressing  of  iodoform  gauze  are  the  best  dressing. 

Mr.  Makins  describes  (Lancet,  1894,  vol.  ii.  p.  1141)  a  method  of 
restoring  the  urethra  in  hypospadias,  in  A^diich  Thiersch's  operation  is 
ingeniously  modified.  By  the  use  of  three  tiers  of  suture  not  only  is 
the  new  urethra  built  up  firmly,  but  the  prepuce  is  restored  as  well. 

iii.  Joinimj  tlie  Old  and  New  Urethra. — As  soon  as  the  new  urethra  is 
thoroughly  established,  quite  closed,  and  shows  no  sign  of  contraction, 
this  last  stage  may  be  undertaken.  The  edges  of  the  posterior  end  of 
the  new  urethra  and  those  of  the  remaining  orifice  having  been  freely 
vivified,  and  a  catheter  passed  from  the  meatus  into  the  bladder,  the 
opening  is  closed  over  it  by  sutures  as  in  stage  ii,  A  catheter — one  of 
Jaques'  pattern  is  least  painful — should  be  kept  in  the  bladder  if 
possible  till  all  is  water-tight. 

2.  Russell's  Method  (Brit.  Med..  Journ.,  Nov.  17,  1900). — Mr. 
Hamilton  Russell,  of  Melbourne,  describes  the  following  method  which 
he  has  devised  and  used  successfully  on  a  boy,  aged  9,  the  subject  of 
hypospadias  of  the  perineeo-scrotal  type.  In  view  of  the  excellence  of 
the  result  in  the  above  case,  the  method  is  well  worth  a  trial.  The 
operation  is  performed  in  two  stages,  and  is  described  by  ]\Ir.  Russell 
as  follows : — 

First  Operation. 

A  thread  is  passed  through  the  glans  penis  to  serve  as  a  tenaculum 
and  the  glans  drawn  upwards. 

Step  I. — An  incision  through  the  frtenum  which  binds  down  the 
glans.  This  incision  may  be  carried  at  once  right  down  the  penis,  so  as 
tu  divide  the  prepuce  on  the  dorsum  by  a  circular  sweep,  not  too  close 
to  the  corona.  The  tip  of  the  left  index  finger  is  inserted  into  the 
gaping  wound  in  the  concavity  of  the  penis,  and  the  structures  which 
bind  it  down  are  felt  and  divided  b}^  successive  cuts  with  scissors.  In 
this  way  will  be  divided  a  number  of  dense  fibrous  bands  and  portions 
of  the  sheaths  of  the  corpora  cavernosa,  and  the  scissors  must  be  freely 
used  until  the  penis  is  quite  released  and  can  be  drawn  out  straight. 
There  will  now  be  a  great  length  of  raw  surface  exposed  between  the 
extremity  of  the  perin^eal  urethra  and  the  glans,  and  the  median  sulcus 
between  the  corpora  cavernosa  may  be  deepened  by  a  little  careful 
dissection,  and  removal  of  the  remains  of  the  longitudinal  fibrous  bands 
that  have  been  divided  (Fig.  179  ;  the  shaded  portion  shows  the  shape 
of  the  raw  surface  exposed). 

(S'^ejy  II. — Perforation  of  the  glans  for  the  reception  of  the  glandular 
urethra  : — A  tenotomy  knife,  with  the  edge  turned  towards  the  dorsum 
of  the  organ,  is  thrust  through  the  substance  of  the  glans,  close  to  the 
under  surface ;  the  structure  is  incised  freely  towards  the  dorsum, 
leaving  a  capacious  channel  through  its  substance. 

Step  III. — -The  incision  indicated  by  the  dotted  lines  ee'  (Figs.  179 
and  180),  starting  near  to  the  extremity  of  the  perinteal  urethra,  about 
one-third  of  an  inch  or  less  from  the  ciit  margin  of  the  skin,  the  incision 


454 


OPERATIONS  OX  THE  ABDOMEN. 


is  carried,  always  parallel  to  the  cut  margin,  over  the  dorsum  of  the 
penis  to  the  corresponding  point  on  the  opposite  side.  By  this  incision 
a  strip  of  prepuce  will  be  marked  out  which  surrounds  the  penis  in  a 
manner  closelj^  resembling  a  clergyman's  stole  (Figs.  179  and  180). 
This  loop  of  skin  is  then  detached  from  its  connections  everywhere 
except  at  its  extremities,  and  slipped  over  the  end  of  the  penis,  exactly 


Fig.  178. 


Fig.  179. 


Fig.  180. 


as  a  clergyman  removes  his  stole.  The  loop  of  prepuce  is  then  simply 
manipulated  so  that  the  cutaneous  surfaces  are  placed  in  apposition,  the 
raw  surfaces  being  turned  outwards ;  a  sinus-forceps  is  passed  through 
the  channel  in  the  glans,  the  loop  seized  and  pulled  through  (Fig.  181). 
The  redundant  portion  of  the  loop  is  then  cut  off,  and  the  two  lateral 
portions  of  the  new  urethra  fixed  in  position  by  one  or  two  stitches  at 
the  meatus  (Fig.  182). 

Step  IV. — Adjustment  and  suturing  of  the  preputial  flaps. — On  the 
dorsum  of  the  penis  this  is  just  a  simple  procedure,  as  in  circumcision. 
On  the  under  surface  of  the  organ,  where  the  prepuce 
is  made  to  cover  over  the  two  edges  of  the  new  urethra, 
these  edges  should  be  included  in  the  sutures,  so  that 
in  each  suture  four  cutaneous  edges  are  brought  to- 
gether, namely,  two  of  prepuce  and  two  of  new  urethra 
(Fig.    181).     Before    finally  tying   these    sutures,   in- 
spection should  be  made  of  the  spot  where  the  perinaeal 
urethra    becomes    continuous    with    the    new    penile 
urethra ;  a  nipple-like  projection   of  skin  is  likelj^  to 
be  present  at  this  place  and  should  be  snipped  off  with 
scissors. 
The  posterior  (or  dorsal)  edges  of  the  new  urethra  will  be  adjusted  in 
the  mesial  sulcus  between  the  corpora  cavernosa,  and  will  not  require 
any  suturing.      The  sutures  having  been  tied,   a  narrow  bandage  of 
iodoform  gauze  may  be  then  wound  round  the  organ,  and  left  undisturbed 
for  several  days.     The  result,  when  completed,  is  portrayed  in  Fig.  182. 
It  is  scarcely  necessary  to  remark  that  no  rod  of  any  kind  should  be 
inserted  in  the  new  urethra.     Should  there  be  any  defect  in  the  success 


EPISPADIAS. 


455 


of  this  operation,  it  would  be  wise  to  remedy  it  before  finally  proceeding 
to  the  closure  of  the  perinseal  urethra. 

Second  Operation  :  Supra-pubic  Cystotomy  and  Closure  of  the 
Perinseal  Urethra. 

This  last  is  really  by  far  the  most  difficult  part  of  the  whole  proce- 
dure, and  demands  care,  skill,  and  experience  in  this  kind  of  plastic 
work.  To  the  operator  who  brings  these  qualities  to  the  task,  however, 
success  will  come  easily.  There  is  one  point  of  paramount  importance 
to  the  success  of  this  part  of  the  operation.  It  is  necessary  to  define 
accurateh'  the  ridge  where  the  urethral  mucous  membrane  merges  into 
the  skin  of  the  perineum ;  the  separation  between  the  two  must  be 
made  exactly*  at  this  ridge,  and  it  is  best  accomplished  by  taking  a 
delicate  pair  of  scissors  and  cutting  off  the  crest  of  the  ridge  all  the  way 


Fig.  i8i. 


Fig.  182. 


round.  It  will  be  necessary  to  incise  the  skin  of  the  perinaeum 
posteriorly  to  a  small  extent,  in  order  to  expose  the  hinder  margin  of 
the  urethral  orifice.  The  reason  for  such  great  precision  on  this  point 
is,  that  if  any  of  the  perinatal  skin  be  left  attached  to  the  iirethral 
margin  at  any  spot,  the  attempt  at  closure  will  certainly  fail  at  this 
point ;  while  if,  on  the  other  hand,  the  incision  is  so  made  as  to  leave 
any  portion  of  the  urethral  wall  attached  to  the  perinseal  skin,  that  will 
be  a  sacrifice  of  iirethral  wall  which  can  by  no  means  be  afforded.  The 
edges  of  the  urethra  should  now  fall  naturally  together  when  the  thighs 
are  approximated,  and  they  need  not  be  sutured.  The  perinseal  skin 
should  be  undercut  slightl}-  and  approximated  by  a  few  sutures,  and  the 
wound  dressed  with  a  layer  of  gauze  and  collodion.  Should  healing 
have  taken  place  throughout,  the  bladder  drain  may  be  removed  in  a 
fortnight. 


I 


EPISPADIAS. 

I  shall  not  give  any  really  full  account  of  the  difierent  attempts  to 
cure  this  rare  condition.  For  some  points  of  practical  importance  I 
would  refer  my  readers  to  the  remarks  on  Hypospadias  (p.  451). 


456  OPERATIONS  OX  THE  ABDOMEN. 

Any  attempt  at  curing  epispadias  shonld  be  divided  into  three  stages, 
thus  : — 

i.  Straightening  the  Penis. — While  the  penis  is  short,  recurved,  so  as 
to  lie  in  contact  with  the  abdominal  wall,  it  is  no  use  trying  to  complete 
the  defective  urethra.  Attempts  should  be  made  to  straighten  the  penis 
by  dividing  it  subcutaneously  close  to  the  pubes.  each  corpus  caver- 
nosum  being  cut  separately.  In  the  only  case  in  which  I  practised  this, 
in  a  patient,  aged  1.7,  the  hgemorrhage  was  easily  controlled  by  dry 
gauze  and  light  pressure,  but  very  sharp  tenotomes  must  be  employed, 
as  the  erectile  tissue  offers  much  less  resistance  than  a  tendon.  Each 
corpus  cavernosum  should  be  divided  completely,  and  as  cleanly  as 
possible.  The  penis  must,  for  some  time,  be  kept  fastened  down ; 
improvement  in  its  position  takes  place  gradually,  together  with  increase 
in  its  length,  this  being,  eventually,  more  marlced  the  earlier  the  opera- 
tion is  performed. 

ii.  Completion  of  the  Deficient  Urethra  from  the  Meatus  to  the  Epispa- 
diac  Opjening. — The  simplest  way  of  effecting  this  is  by  the  method  of 
Thiersch  and  Duplay,  much  as  in  hypospadias,  to  the  account  of  which 
I  would  refer  my  readers.  Two  narrow  quadrilateral  flaps,  extendiug 
from  the  meatus  to  the  epispadiac  orifice,  are  marked  out  and  dissected 
up  from  without  inwards  on  either  side  of  the  open  urethra,  both  being 
left  attached  in  the  middle  line.  These,  turned  with  their  muco- 
cutaneous surface  inwards,  over  a  small  Jaques'  catheter,  to  form  the 
new  urethra,  and  their  raw  surfaces  outwards,  are  united  in  the  middle 
line  with  numerous  points  of  sutures  cut  short  and  buried  (p.  452). 
Thin  flaps  dissected  vip  from  within  outwards  from  off  the  dorsum  and 
sides  of  the  penis  are  then  drawn  inwards,  raw  surfaces  being  thus 
opposed  to  raw  surfaces,  and  kept  in  situ  by  numerous  points  of  suture. 

iii.  Junction  of  the  Old  and.  New  Canal  hi/  Closiire  of  the  Epispa- 
diac Opeidng. — This  is  effected  by  freely  refreshing  the  surrounding 
parts  and  suturing  them  carefully.  Before  the  union  is  complete  several 
operations  may  be  required,  both  for  this  condition  and  hypospadias. 

A  modification  of  Russell's  operation  for  hypospadias  might  also  be 
used  here. 

CIRCUMCISION  (Figs.  183,  184,  185). 

Trivial  as  this  operation  seems,  it  is  so  important,  especially  in  adults, 
to  secure  speedy  healing,  that  it  will  be  briefly  alluded  to  here. 

Indications. — This  operation  is  still  not  practised  often  enough, 
especially  amongst  j^oorer  patients,  where  many  practitioners  still  treat 
phimosis  as  a  matter  of  but  little  importance.  Hospital  surgeons  have, 
only  too  often,  opportunities  of  seeing  the  following  results  follow  from 
the  above  course  : — (a)  Balanitis  and  adhesions,  (h)  Paraphimosis,  from 
the  forcible  retraction  of  a  phimosed  prepuce,  (c)  From  the  impediment 
to  micturition,  urethral  and  vesical  irritation,  and  even  cystitis,  may  be 
set  up,  simulating  the  symptoms  of  stone.  (dJ)  Hernia  and  prolapsus 
recti.       (e)   The   sexual   feelings   too  early  induced,  and  bad  habits.* 

*  Prof.  Sayre  QOrtJiopcedic  Surf/cry,  p.  14)  describes  cases  in  which  paralysis  of 
certain  groups  of  muscles,  leading  to  talipes  and  other  deformities,  followed  on 
early  sexual  excitement,  due  to  phimosis.  See  also  the  case  recorded  by  Mr.  Hilton 
(^Rcst  and  Pain,  p.  276). 


CIRCUMCISION. 


457 


Fig.  183. 


(f)  Impediments  to  intercourse,     (f/)  Intensified  gonorrhoea,  chancres, 
&c.     (h)  Epithelioma. 

Operation. — This  may  be  performed  in  many  different  ways,  but  the 
following-  points  must  be  remembered  in  every  case:  (i)  To  remove 
enough  of  the  mucous  la3'er 
of  the  prepuce.  If  this  be 
not  done,  some  tension  on  the 
glans  remains,  and  this  leads, 
especially  in  adults,  to  trouble- 
some erections  which  interfere 
very  much  with  the  process 
of  healing ;  later  on,  some  de- 
gree of  phimosis  is  certain  to 
persist.  (2)  Not  to  leave  too 
much  tissue  about  the  fragnum. 

Mr.  Howse  [Gun's  Hosp. 
Eeports,  1873,  p.  239)  has 
drawn  attention  to  the  fact 
that  the  cellular  tissue  at  this 
spot  is  loose,  and  that  the 
presence  of  the  frtenal  artery 
makes  probable  the  gatherins 


(I,  h,  Shows  the  line  of  incision  by  which  the 
prepuce  is  removed,  c,  The  point  of  constric- 
tion of  the  mucous  membrane  whicii  causes  the 
phimosis.  The  finer  dotted  line  shows  the  mu- 
cous membrane  lining  the  prepuce  and  covering 
the  glans.     (Davies-CoUey.) 


Fig.  184. 


/'^^" 


of  blood  and  inflammatory 
eflfusion  at  this  spot.  In  children  this  is  a  matter  of  less  importance, 
but  in  adults  it  may  lead  to  the  formation  of  a  tediously  persistent 
lump,  interfering  with  the  function  of  the  organ. 

(3)  Not  to  remove  too  much  of  the  pre- 
puce. Thus,  it  is  always  well,  in  adults 
especially,  to  leave  enough  to  cover  easily 
the  sensitive  papillae  with  which  the  corona 
abounds.  Again,  in  the  diminutive  penis 
of  infants,  it  is  very  easy  to  remove  so  much 
as  to  nearly  flav  the  bodv  of  the  org-an. 

The  following  is  a  very  simple  mode  of 
operating  :  The  prepuce  having  been  separ- 
ated as  much  as  possible  from  the  glans 
with  the  finger  and  thumb,  or  a  stout  probe, 
a  pair  of  dressing-forceps  is  lightly  placed 
on  the  penis  at  a  level  with  the  corona  ; 
the  glans  being  next  allowed  to  sli])  back, 
the  forceps  are  closed,  and  all  the  prepuce 
in  front  of  the  instrument  is  cut  off  with 
a  sharp  scalpel  used  with  a  rapid  sawing 
movement.  The  following  directions  given 
by  Mr.  Uavies-Colley  (Gui/'s  Hosp.  L'ep..  1892, 
p.  164)  are  worth  remembering  at  this  earl}' 
and  most  important  stage  of  the  operation  : 
"The  incision  should  begin  upon  the  dorsum, 
at  a  point  corresponding  to  that  part  of  the 
glans  which  is  halfway  between  the  meatus  and  corona.  The  incision 
should  be  made  downwards  and  forwards,  so  as  to  leave  a  sharp  point 
in  the  middle  of  the  under  surface  (Figs.  183,  184).     The  object  of  this 


The  pointed  process  of  skin 
{b)  is  shown  adjusted  in  the 
angle  left  by  the  remains  of 
the  frreniim.  The  dotted  line 
{b,  d,  e)  shows  the  edge  left  on 
the  skin  and  the  triangular  bare 
siirface  which  has  to  heal  by 
grauiilation  unless  jirecautions 
are  taken  to  preserve  tlie  tri- 
angular flap  of  skin  as  directed 
above.     (Davies-Colley.) 


45  8  OPERATIONS  ON  THE  ABDOMEN. 

pointed  projection  is  to  fill  up,  subsequentlj^  the  triangular  interval, 
which  is  otherwise  left  when  the  portion  of  the  mucous  membrane  of 
the  prepuce,  to  which  the  frtenum  is  attached,  is  removed.  The  blades 
being  at  once  i-emoved,  the  mucous  membrane  is  then  slit  up  wdth  a 
director  and  scissors  or  a  sharp-pointed  bistoury,*  this  incision  running 
up  to,  but  not  beyond,  the  corona.  The  mucous  membrane,  if  still 
adherent,  must  be  jpeeled  in  two  flaps  from  off"  the  glans,  this  detach- 
ment being  effected  by  the  finger  and  thumb,  or  by  a  stout  probe  swept 
round.  The  cut  edges  of  the  prepuce  are  then  rounded  off  with  scissors, 
which  follow  the  curve  of  the  glans  as  far  as  the  frgenum.  Just  a  frill 
of  mucous  membrane,  and  no  more,  should  be  left  all  the  way  round 
the  corona  (Fig.  185).  Enough  prepuce  should  be  left  to  cover  over 
the  corona-papillee,  and  to  admit  of  easy  stitching.  Chromic  gut  and 
horsehair  make  the  best  sutures.  Very  fine  needles  should  be  used, 
and  the  sutures  passed  quickly  through  skin  and  mucous  membrane 
with  a  stabbing  movement,  and  without  bruising  the  edges  with  forceps. 
In  passing  the  sutures  any  bleeding-points  must  be  transfixed,  and  the 

abundant   cellular   tissue  kept   in  its 
Pj(j   j82_  place  with  the  point  of  a  probe.     This 

cellular  tissue  must  on  no  account  be 
cut  away,  as  in  it  run  the  vessels  to 
the  prepuce.  All  bleeding  must  be 
stopped,  especially  in  adults,  or  extra- 
vasation of  blood  in  the  loose  con- 
nective tissue  leads  to  tension,  cutting 
through  of  sutures,  and  sloughing. 
The  frgenum  is  now  attended  to,  the 
^  -^  prepuce  which  is  still  attached  here 
'^  being  cut  away  carefully  by  V-shaped 

The  penis  after  the  edge  of  skin  has     ^^       pointing    forwards,    and    leaving 
been  sr.tiired  to  the  frill  of  mucous  mem-     .         '    ^  ^      n  ,  ,  i  ■ 

brane   left  along  the  corona.     (Davies-    J^^St    enough   flaps   tO  Carry  the  SUturCS 

Colley.)  fiud  no  more.     The  frasnal  artery  can 

usually  be  secured  by  transfixing  it 
with  one  of  the  sutures  ;  if  not.  it  is  readily  tied  with  a  fine  chromic- 
gut  ligature. 

I  much  prefer  interrupted  sutures  of  chromic  gut  for  circumcision  ;  a 
continuous  suture  often  gives  good  results  in  healthy  subjects,  but  the 
former  has  the  great  advantage  that  one  or  two  can  be  removed,  if 
needful,  without  interfering  with  the  rest.     The  majority  soften  awa^^ 

One  of  the  following  dressings  will  be  found  the  best.  I  like  most 
of  all  the  dry  gauze  dressing  advised  by  Mr.  Ballance  {^St.  Thomases 
Hosp.  Repwts,  vol.  xvi.  p.  198),  kept  in  place  b}'  iodoform  and  collodion. 
When  the  parts  are  at  all  swollen,  or  where  erections  are  likely  to  be 
troublesome,  I  prefer  boracic-acid  dressings,  two  laj^ers  of  boracic-acid 
lint  wrung  out  of  an  iced  saturated  solution  of  the  lotion.  The  deeper 
layer  has  a  hole  cut  to  allow  of  micturition  and  is  only  removed  by 
the  surgeon,  the  outer  one  envelopes  the  whole  penis,  and  may  be 
removed  and  re-wetted  by  the  patient,  though  usually  it  is  sufficient 
for   him  to  keep  it  wet  by  dropping  on  a  little  lotion  from  time  to 

*  It  is  well  at  this  stage  to  make  tension  on  the  loose  prepuce  with  two  pairs  of 
dissecting  forceps,  and  thus  secure  a  clean  section. 


AMPUTATIOX  OF  THE  PENIS.  459 

time.  For  children  and  hospital  practice  I  have  come  to  the  conclusion 
that,  on  the  whole,  nothing  answers  better  than  carbolic  oil.  The 
dressing  is  not  disturbed  for  two  or  three  days,  and  the  mother  has 
instructions  to  keep  it  moist  by  oil  dropped  on  at  intervals. 

After  circumcision  the  patient  should  rest  as  much  as  possible.  Thus, 
an  adult  should  stay  in  bed  for  forty-eight  hours  and  keep  on  the  sofa 
for  a  week,  alternate  stitches  being  removed  at  intervals.  If  he  insist 
on  getting  about  too  early,  he  must  run  the  risk  of  the  parts  remaining 
long  oedematous  and  tender.  And  for  this  reason,  with  hospital  patients, 
who  have  to  come  backwards  and  forwards,  early  and  complete  healing 
is  not  to  be  expected. 


AMPUTATION    OF    THE    PENIS  (Figs.  1 86- 1 89). 

Indication. — Epithelioma  of  Penis. — I  would  refer  my  readers  to  the 
remarks  made  in  Vol.  i.  p.  448,  on  the  pre-cancerous  stage  in  epithelioma 
of  the  tongue.  Though  epithelioma  of  the  penis  is  much  less  common, 
lives  are,  here  also,  too  often  lost  by  allowing  the  case  to  get  beyond  this 
stage.  Any  suspicious  excoriation,  ulceration,  or  wart  should  be  early 
destroyed  with  the  acid  nitrate  of  mercury,  or  excised.  Where,  after 
this  treatment,  satisfactory'  healing  does  not  take  place,  early  and 
thorough  removal  of  the  part  should  be  performed.  There  should  be  no 
dangerous  waiting,  because  the  surgeon  is  unable  to  satisfy  himself 
whether  the  case  is  one  of  inflammatory  induration  or  infiltration  from 
new  gTOwth.  In  such  cases,  especially  where  there  is  a  doubtful  history 
of  syphilis,  much  valuable  time  has  been  often  lost  \\"ith  drugs,  wliich, 
even  if  the  lesion  does  date  back  to  some  long-past  syphilis,  are  quite 
useless  if  epitheliomatous  ulceration  has  set  in.  Furthermore,  the 
longer  ulceration  continues,  the  more  extensively  will  the  inguinal 
glands  be  involved.  In  such  cases,  though  the  penis  may  be  satis- 
factorily operated  upon,  disappointment  will  speedily  follow,  owing  to 
the  outbreak  in  the  inguinal  regions.  Scarcely  any  surgical  case  pre- 
sents a  close  more  distressing,  both  to  the  patient  and  those  around  him, 
than  one  of  breaking  down  of  epitheliomatous  glands,  owing  to  the 
hideous  ulceration,  the  noisome  discharge,  and  the  steady  decay  of 
bodily  strength. 

In  a  very  few  cases,  when  the  disease  commences  around  the  meatus, 
it  may  still  be  possible  to  remove  the  affected  part  without  interfering 
with  the  body  of  the  penis.  It  seldom  happens,  however,  that  we  see 
the  case  early  enough  for  this,  and  it  is  usually  necessary  to  remove  the 
whole  of  the  glans  and  more  or  less  of  the  corpora  cavernosa.  Before 
doing  this  the  prepuce,  unless  it  admits  of  being  retracted,  should 
invariably  be  laid  open,  so  as  to  expose  the  gro\\th  and  make  quite  sure 
of  its  real  nature. 

Operations. 

I.  Galvanic  Cautery. — I  am  as  much  against  this  method  here  as  in 
the  case  of  the  tongue  (Vol.  i.  p.  464).  The  dread  of  htemorrhage  still 
induces  some  to  resort  to  it ;  it  is  not,  however,  a  sure  preventive. 
Sharp  bleeding  has  followed  a  few  hours  after  the  operation,  and  also, 
later  on,  during  the  detachment  of  sloughs  ;  furthermore,  this  operation 
leaves  a  much  more  troublesome  and  sloughy  wound  than  the  knife. 


46o 


OPERATIONS  ON  THE  ABDOMEN. 


This  is  not  a  matter  of  slight  importance  in  these  patients,  in  whom, 
usually  advanced  in  years  or  prematurely  aged,  pulled  down  in  health, 
and  often  depressed  in  mind,  tedious  healing  of  the  wound  (which  it 


Fig.  i86. 


Flap  amputatiou  of  the  penis.  The  appearance  of  the  stump,  with  the  urethra 
slit  up  and  stitched  m  situ,  is  shown  above.  The  flap  has  been  raised  too  near 
the  disease  below. 

is  difficult  to  keep  sweet)  involves  keeping  the  patient  on  his  back  for 
a  considerable  time,  with  the  risks  of  broncho-pneumonia,  erysipelas, 
&c.  The  need  of  a  special,  expensive  instrument,  and  the  unpleasant 
foetor  of  the  operation,  are  also  objections. 

Fig.  187. 


A  case  of  amputation  of  the  penis  by  the  flap  method  one  year  and  a  half  after 
the  operation.  Scars  of  operations  for  the  removal  of  glands  (enlarged  inguinal 
glands  were  removed  at  the  time  of  the  operation)  are  seen  in  either  groin.  The 
two  dots  mark  the  points  where  drainage  tubes  were  brought  out.  The  patient 
died  two  years  after  the  amputation  of  gland  disease.  There  never  was  any  re- 
currence in  tlie  penis.     {Bineascs  of  Male  Ovjaiis  of  Generation.) 

If  the  surgeon  make  use  of  it,  a  No.  4  or  6  catheter  should  first  be 
passed  ;  the  loop  of  wire  is  then  tightened  around  the  penis,  well  behind 
the  disease,  and  kept  there  by  one  or  two  pins.  When  the  current  is 
passed  care  must  be  taken  that  by  tightening  the  wire  very  slowly,  and 


AMPUTATION  OF  THE  PENIS. 


461 


•watching  the  amount  of  heat,  the  vascular  structures  are  not  severed  too 
quickly ;  otherwise  haemorrhage,  very  difficult  to  arrest  on  a  seared 
surface,  is  certain  to  follow.  The  catheter  is  cut  through  by  the  heated 
wire,  and  the  urethra,  thus  maintained  patent,  is  slit  up  and  stitched  as 
directed  belo\\-. 

II.  Circular  Amputation. — This  gives  good  results,  though  not 
equal,  in  my  opinion,  to  those  which  follow  the  flap  method.  The 
vessels  being  commanded  the  skin  is  drawn  a  little  forward  to  prevent 
any  superabundance  afterwards,  and  the  amputation  is  effected  by  a 
single  sweep  of  the  knife.  The  vessels  and  the  urethra  are  treated  as 
directed  below. 

III.  Flap  Amputation  (Figs.  186.  187J. — This  method  has  been  fol- 
lowed by  rapid  healing,  and  has  given  an  excellently  covered  stump  in 

Fig.  1 88. 


"% 


Appearance  of  parts  after  amiiutation  of  two-thirds  of  the  penis  by  splitting 
the  scrotum.  The  patient  refused  castration.  The  urethra  is  at  the  lowest  part 
of  the  scar.     (Diseases  of  Male  Organs  of  Generation.) 

the  eleven  cases  in  which  I  have  made  use  of  it.  Haemorrhage  having 
been  provided  against  by  one  of  the  above-given  means,  the  surgeon 
enters  a  narrow-bladed  knife,  at  a  point  well  behind  the  disease,  between 
the  corpus  spongiosum  and  the  corpora  cavernosa,  and  then  cuts  forward 
and  downwards  for  about  three-quarters  of  an  inch.  From  this  small 
inferior  flap  the  urethra  is  dissected  out.  A  flap  of  skin  is  now  cut  from 
the  dorsum  and  sides  of  the  penis,  resembling  in  miniature  the  upper 
skin-flap  in  amputation  of  the  thigh.  This  flap  being  held  back,  the 
corpora  cavernosa  are  divided  vertically  upwards  on  a  level  with  the 
point  of  transfixion.  Any  vessels  which  can  be  seen  are  now  tied  with 
chromic   gnit   or   carbolised   silk.     On   removal   of  the   drainage-tube, 


462 


OPERATIONS  ON  THE  ABDOMEN. 


clamped  with  Spencer  Wells's  forceps,  and  securing  any  spirting- 
vessels,  free  oozing  often  takes  place,  but  ceases  spontaneously.  All 
hsemorrhage  being  arrested,  the  upper  flap  is  punctured,  and  the  urethra 
drawn  through  the  face  of  the  flap,  slit  up,  and  stitched  in  situ.  The 
two  flaps,  upper  and  lower,  are  then  united  by  a  few  points  of  carbolised 
silk  and  horsehair  suture. 

This  method  secures  a  natural  skin-covering  for  the  severed  corpora 
cavernosa,  and  prevents  the  delay  and  irritation  which  healing  by  granu- 
lation entails.  A  similar  operation  was,  long  ago,  suggested  by  Prof. 
Miller,  of  Edinburgh,  but  this  surgeon  cut  his  flap  from  below.     If,  as 

Fig.  189. 


^ikSM^:  y  . 


The  appearance  of  the  parts  a  month  after  complete  amputation  of  the  penis, 
castration,  and  removal  of  enlarged  glands.  The  opening  ot  the  urethra  is  not 
seen,  being  situated  at  the  perinseo-scrotal  junction.  The  dots  mark  the  counter- 
punctures  for  drainage-tubes.    {Diseases  of  Male  Organs  of  Generation.) 

I  have  recommended,  the  flap  is  taken  from  above,  the  skin  will  be 
found  to  fall  into  position  more  readily  over  the  raw  surfaces  of  the 
corpora  cavernosa.  After  all  these  operations  the  patient  should  pass  a 
short  piece  of  bougie  at  regular  intervals. 

Occasionally,  severer  operations  are  entirely  justifiable. 

Thus,  where  the  penis  is  involved  as  far  back  as  the  scrotum,  the 
entire  penis  should  be  extirpated,  if  the  inguinal  glands  are  not  seriously 
involved,  and  if  the  powers  of  repair  are  satisfactory.  The  patient 
being  in  lithotomy  position,  the  scrotum  is  to  be  split  deeply  along  the 
whole  length  of  the  raphe,  and  the  corpus  spongiosum  carefully  dis- 
sected out.     This  step  may  be  facilitated  by  passing  a  large  sound. 


AMPUTATION  OF  THE  PEXIS.  463 

When  the  triangular  ligament  is  exposed,  the  above  instrument  is 
removed,  and  the  corpus  spongiosum  which  has  been  dissected  out  is  cut 
through,  enough  being  left  to  bring  out  in  the  perineum.  By  means 
of  a  blunt  dissector,  the  crura  are  then  detached  on  either  side  from  the 
pubic  arch,  and  the  incision  being  prolonged  around  the  penis  above, 
the  suspensory  ligament  is  divided,  and  the  dorsal  arteries  secured. 
The  cut  end  of  the  corpus  spongiosum  is  now  slit  up  and  stitched  in  the 
posterior  part  of  the  scrotal  incision,  and  all  the  rest  of  the  wound  closed 
by  sutures.  Drainage  must  be  provided  by  a  small  tube,  or  by  horse- 
hair drains.  Similar  operations  to  the  above  have  been  performed  on 
several  occasions,  but  the  important  modification  of  dissecting  off  the 
crura,  and  thus  ensuring  complete  removal  of  the  cancerous  organ  and 
its  capsule,  was  brought  before  the  notice  of  English  surgeons  by  Mr 
Gould  (Lancet,   1882,  May  20,  p.  821). 

In  most  cases  of  amputation  of  the  penis  the  patients  will  be  wise  in 
consenting  to  castration —an  operation  which  will  add  in  many  cases 
largely  to  their  comfort,  and  at  a  very  slightly  increased  risk.  (Wheel- 
house,  Brit.  Med.  Journ.,   1886.  vol.  i.  p.   187.) 

Question  of  Removing  Enlarged  Glands. — These  should  always  be 
extirpated  at  the  same  time  as  the  amputation  of  the  penis,  together 
with  as  much  of  the  lymphatic  vessels  and  surrounding  cellular  tissue 
as  possible,  preferably  in  one  piece  in  order  to  avoid  the  escape  of 
cancer  cells  into  the  wound.  As  long  as  the  glands  are  involved  by 
growth  only,  hard  and  separate  from  each  other,  it  will  be  comparatively 
easy  to  accomplish  this,  and  thereby  add  materially  to  the  prolong- 
ation of  the  patient's  life.  But  where  they  contain  not  only  secondary 
deposits,  but  also  inflammatory  matter,  owing  to  ulceration  having  set 
in  at  the  seat  of  the  primary  lesion,  satisfactory  removal  of  the  glands 
is  always  a  matter  of  great  difficulty  and  often  impossible,  owing  to 
their  softness  and  tendency  to  break  do\\Ti,  to  their  adhesions  to  their 
capsules,  and  the  matting  of  these  to  the  surrounding  parts,  the  vascu- 
larity of  which  is  increased,  and  tendency  of  the  overlying  skin  to 
become  adherent. 

In  all  such  operations  the  parts  should  be  disturbed  as  little  as 
possible,  as  erysipelas,  sloughing,  and  superficial  gangrene  are  very 
likely  to  follow  these  operations  where  planes  of  fascia  are  much 
interfered  with,  and  where  the  blood-supply  is  but  poor. 

The  wound  may  be  irrigated  from  time  to  time  during  the  operation 
with  a  solution  of  mercury  perchloride,  I  in  4000. 

Iodoform  and  sal-alembroth  gauze  dressings,  or  boracic-acid  lotion,  if 
erysipelas  is  feared,  will  be  found  the  best. 

For  much  fuller  information  on  this  and  many  other  points  I  may 
refer  my  readers  to  my  Diseases  of  the  Male  Organs  of  Generation, 
pp.  707-745- 


CHAPTER  Xin. 
OPERATIONS  ON  THE  SCROTUM  AND  TESTICLE. 

RADICAL  CURE   OF  HYDROCELE.*— V ARIOCELE.— 
CASTRATION.— ORCHIDOPEXY.— VASECTOMY. 

RADICAL   CURE   OF   HYDROCELE. 

In  a  paper  written  twenty-four  years  ago  (Lancet,  Sept.  i,  1877),!  drew 
attention  to  the  uncertainty  of  the  radical  cure  of  hydrocele  by  iodine 
injection,  as  usually  practised.  Thus,  out  of  forty-four  cases  treated 
with  solutions  of  iodine  and  potassium  iodide  at  Guy's  Hospital,  I  found 
that  the  treatment  failed  in  eight  cases,  and  that  in  two  it  failed 
twice. 

Latterly,  I  believe  that  surgeons  have  recognised  that  the  risk  of 
recurrence  is  greater  than  that  of  excessive  inflammation,  and  thus 
stronger  solutions  have  been  made  use  of — e.g.,  the  Edinburgh  tincture 
of  iodine — and  some  of  the  injection  has  been  allowed  to  remain.  As  it 
is  still  a  fact,  however,  that  no  one  method  of  cure  can  always  be  relied 
upon  as  radical  for  this  troublesome  complaint  the  three  folloAving 
will  be  mentioned  here — viz. : 

i.  Iodine  Injection,  ii.  Injection  of  Carbolic  Acid. 
iii.  and  iv.  Partial  Excision. 

Iodine  Injection. — Supposing  the  patient  be  health}',  not  pre- 
maturely aged,  and  amenable  to  directions,  the  surgeon  often  begins 
with  this  as  less  painful,  requiring  no  open  wound  or  dressing,  and 
finally,  as  necessitating  much  less  the  recumbent  position. 

I  have  at  p.  466  drawn  attention  to  the  frequency  with  which  recur- 
rence is  liable  to  take  place  if  dilute  injections  are  used.  Elsewhere 
I  have  written  as  follows  :  "  While  I  believe  that  the  absolute  certainty 
of  iodine  injection  has  been  over-estimated,  yet  there  is  no  doubt  that 
failure  is  too  often  courted  by  want  of  the  following  precautions  : — (a) 
The  use  of  a  too  dilute  solution ;  (h)  Not  bringing  the  solution  in  con- 
tact ^^■ith  the  whole  of  the  sac ;  (c)  Not  withdrawing  all  the  h}rdrocele 
fluid  ;    (d)  Injecting    large    hydroceles    immediately   after    they    are 

*  The  methods  of  injection  given  below  refer  to  hydrocele  of  the  tunica  vaginalis 
and  to  encysted  hydrocele.  Antiseptic  incision  and  partial  excision  of  the  sac  is 
applicable  to  all  varieties  of  hydroceles,  including  the  congenital. 


RADICAL  CURE  OF  HYDROCELE.  465 

emptied ;  (e)  Making-  use  of  iodine  in  unsuitable  cases — viz.,  hydroceles 
with  thick  walls. 

The  method  of  injection  irith  iodine  should  be  carried  out  as  follows : 
The  ])atient's  bowels  are  cleared  out  for  a  day  or  two  before,  and  it  is 
well  for  him  to  rest  with  his  hydrocele  well  supported  for  twenty-four 
hours  previous  to  the  injection.  The  fluid  is  first  most  carefully  drawn 
off  with  a  medium-sized  trocar,*  the  surgeon  then,  by  means  of  a 
syringe  with  a  platinum  nozzle  accurately  fitting  the  cannula,  injects 
steadily  2  to  3  dr.  of  the  tincture  of  iodine  (FaUu.  Pharm.),  taking  care 
first  that  the  cannula  is  well  within  the  cavity  of  the  tunica  vaginalis. 
I  now  plug  the  cannula  with  a  small  wooden  spigot,  while  the  affected 
side  of  the  scrotum  is  gently  manipulated  and  shaken  so  as  to  bring  the 
fluid  in  contact  with  all  the  interstices  and  folds  of  the  serous  membrane. 
In  five  or  ten  minutes  the  cannula  is  withdrawn,  as  in  most  cases  it  is 
quite  safe  to  leave  in  the  above  given  amount  of  iodine.  The  puncture  is 
kept  carefully  closed  around  the  cannula  while  this  is  taken  out,  and  then 
closed  with  iodoform  and  collodion.  A  feeling  of  heat  is  noticed  during 
the  injection,  sometimes  amounting  to  sickening  pain,  referred  also  to 
the  inguinal  and  lumbar  regions,  and  the  neck  of  the  bladder.  Faint- 
ness  is  not  very  infrequent,  and  it  is  thus  well  to  tap  and  inject  the 
patient  while  he  stands  at  the  end  of  a  sofa,  or  lies  down. 

The  after-treatment  depends  on  the  amount  of  inflammation.  In 
most  cases  there  is  too  little  rather  than  too  much  of  this.  It  usually 
appears  within  two  or  three  hours,  and  if  it  be  slight  or  delayed,  the 
patient  should  be  told  to  walk  about  a  little,  and  the  sac  again  frequently 
manipulated.  The  patient  should  be  kept  to  his  bed  or  sofa  for  a  day 
or  two,  the  scrotum  supported,  and  plain  diet  given.  There  should  be 
no  hurry  to  employ  ice.  this  only  being  made  use  of  if  the  swelling 
threatens  to  be  great.  Morphia  may  be  given  freely.  Within  four  or 
five  days,  usually,  the  patient  may  get  about  wearing  a  suspender.  He 
should  be  prepared  for  a  return  of  the  swelling  after  the  injection,  other- 
wise he  will  be  disappointed  at  what  he  considers  a  recurrence  of  his 
disease.     The  swelling,  as  a  rule,  disappears  in  three  to  four  weeks. 

In  the  case  of  a  double  hydrocele,  if  the  patient  be  healthy  and  not 
advanced  in  years,  it  is  quite  safe  to  inject  both  sacs  at  the  same  time, 
but  in  elderly  or  weakly  subjects,  antiseptic  incision  will  be  the  safest 
course  if  the  patient  desires  an  operation,  otherwise  an  interval  should  be 
allowed  between  the  two  tappings. 

Carbolic  Acid. — This  method  was  introdviced  in  1881,  by  Dr.  Levis, 
of  Philadelphia  (Boston  Med.  and.  Surij.  Journ.,  1881,  vol.  cv.  p.  540)' 
The  following  adrantaries  have  been  claimed,  and  in  my  opinion  largely 
substantiated  :  (a)  It  is  less  painful  than  iodine.  (/3)  It  is  more  certain. 
Thus,  carbolic  acid  produces  almost  uniformly  the  proper  degree  of 
inflammation,  neither  falling  short  nor  exceeding  that  needful  for  pro- 
ducing plastic  lymph.  (7)  There  is  less  risk  of  sloughing.  (8)  The 
patient  is  only  kept  from  his  employment  for  a  day  or  two.  and  some- 
times for  a  shorter  time  than  this,  or  even  not  at  all. 

While  the  above  advantages  of  carbolic-acid  injection  over  that  by 
iodine,  especially  the  fact  that  it  entails  a  much  shorter  rest  and  absence 

*  By  some  a  solution  of  cocaine  is  now  injected.  I  prefer  not  to  use  this,  if  possible. 
?o  that  no  dilution  of  the  iodine  injection  mar  occur. 

VOL.    II.  30 


466  OPERATIONS   ON  THE  ABDOMEN. 

from  business,  have^  in  my  opinion,  been  largely  siTbstantiated,  it  is 
certain  that  complications  and  undesirable  sequelee,  while  less  frecjuent. 
are  not  so  entirely  uncommon  as  some  partisans  of  this  method 
would  have  us  believe.  (i)  Recurrence. — With  regard  to  this 
matter,  I  would  point  out  that  a  large  number  of  cases  have  been 
published  as  radical  cures  within  a  year  or  so  of  the  first  introduction  of 
the  method.  Thoughtful  surgeons  who  have  seen  much  of  radical  cure 
of  hydroceles  will  not  need  that  I  should  refer  them  to  the  remarks 
which  I  have  made  on  the  rebellious  nature  of  many  hydroceles,  and 
how  they  must  be  carefully  watched  for  an  extended  period  before  a 
radical  cure  can  really  be  claimed.  It  is  beyond  the  bounds  of  proba- 
bility that  while  a  hydrocele  will  recur  after  careful  incision  and 
drainage,  and  even  after  incision  and  partial  excision  of  the  sac, 
injection  of  carbolic  acid  will  be  invariably  and  permanently  success- 
ful. And  it  is  interesting  to  note  that  in  America  itself,  where  this 
method  has  been  most  largely  used,  and  where  surgeons  have  had 
the  largest  opportimities  of  watching  its  results,  they  are  not  in  entii^e 
accord  as  to  its  value. 

Thus,  Dr.  Bull,  of  New  York  (A^m.  of  Surrj.,  July  1886,  p.  35),  in  a 
paper  recommending  antiseptic  incision,  writes,  "  It  is  a  striking  fact 
that  of  the  thirteen  cases  I  have  met  with,  two  had  been  treated 
unsuccessfully  in  this  way.  As  it  attempts  a  cure  by  the  same  process  as 
that  incited  by  iodine,  an  adhesive  inflammation,  I  see  no  reason  to 
believe  that  it  will  ever  yield  much  better  results."  Dr.  R.  F.  Weir,  in 
the  discussion  that  followed  on  the  reading  of  the  above  paper,  said  he 
had  used  carbolic-acid  injections  over  sixty  times.  Occasionally  relapses 
had  occurred,  not  in  a  large  proportion,  however,  as  he  could  recall 
only  four  or  five  instances,  and  in  those  the  patients  were  cured  by  a 
repetition  of  the  same  treatment.  In  three  of  those  the  injection  was 
repeated  too  soon,  as  subsequent  experience  showed  that  a  longer  delay 
would  probably  have  resulted  in  a  cure.  Helferich,  of  Griefswald 
(Therap.  Monatsschrift,  1890),  has  tested  carbolic-acid  injection  by  Levis' 
method  in  over  thirty  cases,  with  known  results  in  twenty-seven  ;  twenty- 
one  were  cared,  six  relapsed  ;  all  of  these  latter,  save  one,  being  cured  by 
a  fresh  injection.* 

(2)  Much  Reaction.  Cellulitis  and  Suppuration. — It  is  right  to  say 
that  in  some  of  the  cases  in  which  this  has  followed  on  the  injection  of 
carbolic  acid  an  excessive  quantity  seems  to  have  been  employed.  Thus, 
Dr.  R.  Abbe  {New  York  Med.  Journ.,  December  22,  1883),  reports  that  he 
injected  three  drachms  of  carbolic  acid  and  glycerine  into  a  large  hydro- 
cele sac,  and  that  acute  suppuration  followed,  requiring  incision,  which 
cured  the  hydrocele.  He  allows  that  the  above  quantity  is  excessive,  one 
drachm  alwa3^s  sufficing.  Dr.  Weir  (loc.  suj)ra  cit.),  in  one  case  in  which 
the  iodine  treatment  had  failed,  injected  three  drachms  of  carbolic  acid ; 
this  was  followed  by  the  usual  aljsence  of  pain,  but  with  recurrence  of 
the  swelling  in  a  few  dajs^  which  went  on  to  suppuration,  and  after  in- 
cision of  the  sac,  shreds  and  large  masses  of  membrane  were  discharged, 
gangrene  of  nearly  the  entire  tunica  vaginalis  being  produced. 

*  Mr.  Southara  (^Lancet,  1887,  vol.  ii.  p  515)  mentions  a  case  which  recurred  within 
the  month  of  the  injection  with  carbolic  acid,  and  was  then  treated  by  antiseptic 
incision  and  partial  excision  of  the  sac. 


RADICAL  CURE  OF  HYDROCELE,  467 

The  above  cases  of  Weir  and  Helferich  show  that  accidents  have 
followed  even  when  the  amount  of  carbolic  acid  used  is  small.  They 
suggest  that,  considering  the  comparatively  recent  introduction  of  this 
method,  and  the  restricted  number  of  surgeons  by  whom  it  has  been  used, 
complications  are  at  least  as  frequent  as  after  iodine  injection. 

(3)  Carbolic  Acid  Poisoning. — Most  writers  have  distinctly  stated 
that  this  does  not  occur.  It  is  certainly  extremely  rare,  as  it  is  probable 
the  surfaces  are  sealed  by  the  carbolic  acid. 

But  Dr.  J.  Murphy,  at  a  discussion  at  the  New  York  Association  (JSfeiv 
Yorlx  Med.  Becord,  June  20,  1891V  said  he  had  known  of  three  or  four 
cases  in  which  carliolic  acid  used  in  this  way  was  followed  by  bad  effects, 
especially  on  the  kidneys.  He  had  seen  one  case  terminate  fatally,  and 
he  could  not  attribute  this  death  to  anything  but  carbolic  acid  poisoning. 
He  did  not  know  how  much  carbolic  acid  was  used. 

The  Injection. — After  the  usual  tapping,  Dr.  Levis,  by  means  of  a 
syringe  which  has  a  nozzle  sufficiently  long  and  slender  to  reach  entirely 
through  the  cannula,  injects  about  a  drachm  (of  crystals)  of  carhoUc  acid, 
which  must  be  kept  liquid  by  a  five  or  ten  per  cent,  addition  of  glycerine 
or  water.  The  former  should  be  preferred.  No  more  fluid  is  to  be  used 
for  dilution  than  is  absolutely  necessary.  Liquefaction  by  heat  is  inad- 
missible, as  solidification  is  in  this  case  liable  to  follow  in  the  cannula. 
As  soon  as  the  carbolic  acid  is  lodged  in  the  sac,  the  scrotum  is  freely 
manipulated,  so  as  to  diffuse  the  carbolic  acid  uniformly.  A  sense  of 
warmth  is  produced,  quickly  followed  by  decided  numbness. 

My  own  experience  is  too  limited  to  be  of  any  value.  Of  late  years  I 
have  used  antiseptic  incision  with  partial  excision  of  the  sac,  and  have 
been  so  well  satisfied  with  it  as  to  prefer  to  use  it  wherever  the  patient 
can  lay  up.  But  where  this  is  objected  to,  I  have  used  iodine  and  car- 
bolic acid,  but  the  latter  only  in  eleven  cases.  None  have  recurred  to 
my  knowledge,  and  some  have  been  watched  for  over  three  years. 
There  is  no  need  of  Levis's  special  instrument.  What  is  essential  is 
to  use  carbolic  acid  liquefied  with  glycerine,  not  to  inject  more  than 
one  drachm,  and  to  lodge  it  well  within  the  tunica  vaginalis.  This 
may  be  done  by  means  of  one  of  the  large  exploring  hypodermic 
needles,  which  hold  60 — 100  minims.* 

The  needle  attached  to  the  syringe  is  first  lodged  safely  in  the  cavity 
of  the  hydrocele,  which  is  then  tapped  in  the  ordinary  way  with  a  fine 
hydrocele-trocar.  When  the  sac  has  been  thoroughly  emptied,  the 
cannula  is  withdrawn,  and  the  syringe,  previously  cleansed,  containing 
the  solution  must  be  screwed  on  to  the  needle,  which  has  been  kept  in  situ, 
and  the  solution  injected.  However  this  is  done  the  carbolic  acid  must 
be  brought  in  as  complete  contact  as  possible  with  the  interior  of  the 
sac,  by  manipulating  the  scrotum,  turning  this  from  side  to  side,  upside 
down,  &c.  I  have  employed  strapping  or  suspension  with  cotton  wool 
packing  later,  as  after  the  use  of  iodine. 

Partial  Excision  of  the  Sac. — This  latter  is  often  spoken  of  as  excision 
of  the  tunica  vaginalis.  As  the  parietal  layer  of  the  serous  membrane 
can  alone  be  removed,  I  prefer  the  above  title. 

*  I  learnt  the  value  of  these  in  small  hydroceles,  as  in  those  of  the  cord,  or  the 
infantile  variety  in  boys,  from  the  late  Mr.  Berkeley  Hill  (_Brit.  Med.  Journ.,  1886, 
vol.  i.  p.  ii6j).     Following  Mr.  Hill,  I  have  also  given  an  anaesthetic  in  childicu. 


468  OPERATIONS  OX  THE  ABDOMEN. 

A.  Advantages. 

(i)  Its  greater  certainty.  While  it  is  right  to  remember  that  no 
method  can  be  absolutely  relied  upon  as  radical,  and  that  hydroceles  have 
recurred  even  after  incision  and  partial  excision  of  the  sac,*  there  can 
be  little  doubt  that  this  must  be  extremel}^  rare,  since  after  efficient 
removal  of  the  parietal  layer  of  the  tunica  vaginalis,  the  cavity  must, 
with  very  few  exceptions,  be  entirely  obliterated.  A  method  which  further 
removes  a  large  part  of  this  secreting  surface  must  a  lyriori  be  surer 
than  those  methods  which  do  their  work  as  it  were  in  the  dark,  in  which 
the  drainage  must  needs  be  imperfect,  the  quantity  of  the  irritant  em- 
ployed necessarily  limited,  it  being  thus  always  left  doubtful  how  far 
the  injection  has  been  weakened  by  dilution  or  chemical  change,  and 
how  far  folds  of  the  inner  surface  of  the  tunica  vaginalis  have  escaped 
inflammation  at  all.  On  this  account  I  prefer  to  make  use  of  partial 
excision  in  all  cases  where  the  general  condition  of  the  patient  is  satis- 
factory, and  where  he  is  willing  to  lay  up  for  a  short  time. 

The  cases  to  which  this  method  appears  to  me  to  be  especially 
suitable  are  those  where  (a)  iodine  or  carbolic  acid  has  previously 
failed,  (/S)  where  the  sac  is  very  large  or  has  very  thick  walls.  Where 
the  sac  is  simply  very  large,  but  not  much  thickened,  it  can  be  safel}' 
and  successfully  injected,  if  this  is  preferred,  by  tapping  first  and  then 
allowing  only  an  interval  of  two  or  three  weeks  to  elapse  before  the  sac 
is  injected.  But  if  the  M'alls  are  much  thickened,  there  are  the  risks 
that  after  tapping  they  cannot  collai^se  readily,  and  so  be  brought  in 
contact  with  the  irritant,  and,  while  in  a  sac  like  this  it  is  always  un- 
certain if  the  due  amount  of  inflammation  will  be  secured,  there  is  also 
a  risk  that  owing  to  the  little  vascularity  of  a  thickened  sac  sloughing 
may  take  place.  (7)  Where,  on  account  of  ill-health  or  age,  the  risk  of 
inflammation  after  injection  of  an  irritant  is  especially  to  be  dreaded. 
(8)  Where  the  surgeon  is  desirous  of  exploring  the  sac  of  the  tunica 
vaginalis,  as  in  cases  where  enlargement  of  the  testis  of  a  doubtful 
nature  coexists  with  hydrocele,  and  does  not  yield  to  ordinary  treat- 
ment, where  a  hsematocele  has  supervened  on  a  hydrocele,  or  in  the 
nmch  rarer  cases  of  loose  bodies  in  the  sac  of  the  tunica  vaginalis,  (e) 
Where  several  hydroceles  co-exist — e.g.,  either  double  hydrocele  of  the 
tunica  vaginalis,  or  a  vaginal  and  encysted  hydrocele.  (^)  In  certain 
cases  of  hydrocele  complicated  with  hernia — e.g.,  (i)  in  young  subjects 
where  a  radical  cure  of  both  is  desired,  (2)  in  much  older  patients,  where 
the  hernia  is  irreducible,  where,  especially  in  unhealthy  patients,  there 
is  a  risk  of  the  inflammation  set  up  by  the  injection  extending  to  the 
sac  of  the  hernia.  (7])  In  cases  of  congenital  hydrocele  a  careful  incision 
with  antiseptic  precautions  will  be  safer  than  any  other  method  of 
radical  cure  if  the  pressure  of  a  truss  for  the  obliteration  of  the  com7 
munication  with  the  peritonaeal  sac  cannot  be  persevered  with.     And 

*  On  this  point  a  valuable  paper  by  Mr.  H.  Morris,  followed  by  an  interesting  dis- 
cussion (Med.-Chir.  Soc.,Feb.  28,  1888),  should  be  consulted  (^r?#.  Med.  /owr^i.,  March  3. 
1888).  Two  cases  of  recurrence  after  partial  excision  of  the  sac  were  related.  Mr 
Pollock  mentioned  one  even  more  extraordinary.  This  recurred  repeatedly — i.e.,  after 
two  injections  with  iodine,  the  introduction  of  a  silver  wire  seton  and  "  ample  sup- 
puration " ;  finally,  the  sac  was  laid  open  and  lint  inserted  for  a  fortnight.  The 
hydrocele  again  recurred,  and  the  patient  declined  any  further  treatment  than  simple 
tapping. 


RADICAL  CURE  OF  H\T»ROCELE.  469 

the  same  course  will  be  wise  in  the  case  of  encysted  hj^droceles  of  rhe 
cord,  Avhen  their  important  surroundings,  mobility,  and  their  difficult 
fixation  before  injection  are  considered. 

(B)  The   disadvantages  of  this  method    must  next    be    considered. 

(1)  As  pointed  out  in  my  paper  in  1 877,  it  undoubtedly  involves  nioi'e 
trouble  than  that  by  injection.  While  it  can  be  completed  in  a  quarter 
of  an  hour,  an  anaesthetic  will  be  required,  and  there  is  also  the  troul)le 
of  the  snbsecjuent  dressings,  and  there  is  also  more  need  of  absolute 
rest.  Thus  the  patient  will  be  confined  to  his  bed  for  a  week  or  ten 
days,  and  after  this  will  have  to  keep  quiet  on  a  sofa  or  in  an  armchair. 

(2)  With  regard  to  the  amount  of  subsequent  orchitis,  pain,  swelling, 
Sec,  I  am  of  opinion  that  this  varies,  but  not  as  much  as  after  iodine 
injection.  In  the  early  days  of  this  method — the  Schnitt  method  of 
A'olkmann — when  after  incision  of  the  tunica  vaginalis  this  cavity  was 
carefully  plugged  with  strips  of  aseptic  gauze  to  promote  changes  in 
the  serous  membrane,  orchitis  to  a  painful  degree  was  not  uncommon ; 
but  of  late  years  when,  after  incision  of  the  sac,  the  parietal  layer  of 
the  tunica  vaginalis  is  gently  detached  from  the  scrotum  and  cut  away 
close  to  the  epididyinis  and  the  testis.  I  have  been  extremeh'  struck  by 
the  very  small  amount  of  pain  suffered,  in  spite  of  the  disturbance  and  the 
handling  entailed  of  the  parts  concerned.  (3J  With  regard  to  the 
duration  of  the  after-treatment,  this  is  in  favour,  but  not  so  distinctly 
as  would  appear  at  first  sight,  of  the  injection  method.  With  regard  to 
the  injection  of  carbolic  acid,  this  is  most  certainly  so  (p.  465J.  Iodine 
has  also  an  advantage  in  time  less  clearly  marked.  Thus,  after  injection 
with  carbolic  acid,  the  patient  may  perhaps  not  have  to  lay  up  at  all. 
After  forty-eight  hours  he  will  probably  be  able  to  follow  his  employ- 
ment if  not  an  arduous  one.  After  the  use  of  iodine  the  patient  will 
probably  be  able  to  get  about  after  the  first  week.  But  these  dates  are 
only  approximate  ;  even  with  regard  to  carbolic  acid  it  is  impossible  to 
read  through  a  large  number  of  cases  reported  by  American  and  other 
surgeons  without  seeing  that  inflammatoiy  reaction,  crippling  to  loco- 
motion, does  occur  more  frequently  than  would  be  gathered  from  the 
reports  of  those  surgeons  who  have  advocated  it  most  strongly.  And 
again,  as  is  shown  above,  while  carbolic  acid  is  extremely  convenient, 
it  is  clear  that  there  is  no  absolute  certainty  about  it,  and  that  repeated 
injections  have  been  called  for  in  many  cases.  After  iodine  injection 
the  scrotum  is  often  not  its  natural  size,  and  the  patient  not  free  from 
all  encumbrance  till  between  the  second  and  the  third  week.  By  the 
latter  date,  after  partial  excision  of  the  sac,  the  patient  will  be  quite 
well  and  able  to  get  about.  (4)  As  to  the  risks  of  haemorrhage,  cellu- 
litis, and  sloughing,  which  have  been  described  by  some  writers,  I  can 
only  say  that  I  have  never  seen  them  in  an  experience  of  twenty -one  cases 
of  antiseptic  incision,  and  of  antiseptic  incision  and  excision  of  the  sac. 

Operation. — The  patient  having  been  prepared  for  the  operation,  the 
parts  shaved  and  well  cleansed  with  soap  and  water  used  with  a  flannel, 
and  then  washed  with  a  dilute  solution  of  carbolic  acid  or  mercury  pei- 
chloride,*  ether,  or  A.C.E.  is  given.     The  surgeon,  the  sciotal  tunics 

*  As  it  is  of  the  utmost  importance  that  there  should  be  no  irritation,  or  erythema 
set  up,  which  may  cause  discomfort  and  subsequent  restlessness  and  also  suppuration 
and  slowness  of  healing,  the  antiseptic  solutions,  which  are  all  irritants,  should  be  used 
both  before  or  during  the  operation,  as  dilute  as  is  safe  to  the  very  delicate  scrotal  skin 


470 


OPERATIONS  ON  THE  ABDOMEN. 


Fig. 


190. 


being  made  tense  by  his  left  hand  or  by  an  assistant,*  incises  them 
down  to  the  hydrocele,  from  the  top  to  the  bottom  of  the  swelling,  and 
then,  before  opening  this,  arrests  any  bleeding  points  by  applying 
Spencer  Wells's  forceps.  The  hj^drocele  is  then  opened  sufficiently  to 
admit  a  finger,  which  makes  out  definitely  the  position  of  the  testicle ; 
the  tunica  vaginalis  is  then  freely  but  carefully  slit  up  with  blunt- 
pointed  scissors.  As,  when  the  hydrocele  is  opened,  the  fluid  escapes 
with  much  force,  the  sac  at  once  collapses  into  folds,  and  scissors  will  be 
found  preferable  to  the  knife.  The  incision  into  the  tunica  vaginalis 
should  be  as  free  as  is  safe,  for  a  free  incision  will  at  once  admit  of  rapid 
removal  of  the  parietal  layer  and  a  thorough  examination  of  the  recesses 
of  the  serous  sac.     If  a  small  one  only  is  made,  owing  to  the  contraction 

of  the  dartos,  the  above  steps  will  be  found 
impossible.  Further,  a  large  incision  is, 
b}"  the  above,  soon  folded  into  a  little 
space,  and  heals  as  quicklj^  as  a  small  one. 
Spencer  Wells's  forceps  are  then  applied 
to  every  bleeding  point  in  the  cut  edges 
of  the  sac.  The  forceps  on  either  side 
serving  to  widely  open  out  the  wound,  the 
testis  and  epididymis  are  examined  for  any 
cysts,  sometimes  present  about  the  head 
of  the  latter.  The  inner  surface  of  the 
tunica  vaginalis  is  carefully  scrutinised  for 
any  fibrous  bodies  attached  or  loose  in  any 
of  its  folds,  or  for  false  membranes  and 
thickenings.  As  an}^  of  these  may,  by 
keeping  up  irritation,  lead  to  a  recurrence 
of  the  hydrocele,  they  should  be  dealt  with, 
the  cysts  being  snipped  awa)^  after  ligature 
of  their  pedicles  with  fine  catgut.  The 
parietal  layer  of  the  tunica  vaginalis  is 
now  gently  detached,  or  peeled  away  from 
the  scrotum  as  far  as  is  safe — i.e.,  close 
up  to  the  epididymis  on  the  outer,  and  to 
the  back  of  the  testicle  on  the  inner  side. 
Along  these  limits  it  is  snipped  away  with 
scissors,  and  forceps  applied  to  all  bleeding- 
points.  (Vide  Fig.  190.) 
If  any  false  membranes  are  now  present  over  the  testicle  and 
epididymis  or  the  small  part  of  the  parietal  tunica  vaginalis  that  remains, 
these  are  to  be  detached  with  a  sharp  spoon.  The  bleeding  which 
follows  may  be  smart  and  require  very  hot  solutions  of  mercury  per- 
chloride,  or  firm  pressure  with  a  sponge.  Different  ways  of  closing  the 
Avound  have  been  employed.     In  all  my  cases  I  have  followed  Bergmann, 


Radical  cure  of  hydrocele.  To 
show  the  extent  to  which  the  tu- 
nica vaginalis  is  removed.  (From 
Lockwood's  Hernia,  Hydrocele,  and 

Varicocele. 


— e.g.,  carbolic  acid  i  in  30,  and.  mercury  perchloride  i  in  4000.  For  the  same  reason 
no  scrubbing  with  a  nail-brush  is  advisable.  These  may  seem  trifles,  but  they  may 
have  a  very  important  bearing  on  the  after-result.  To  promote  relaxation  of  the 
dartos  and  prevent  contraction,  and  thus  curling  in  of  the  skin,  warm  solutions  should 
be  used. 

*  The  position  of  the  testis  should  first  be  made  out  by  translucency.     The  more 
showy  step  of  opening  the  hydrocele  at  one  cut  might  endanger  the  cord  and  testicle. 


RADICAL  CURE  OF  HYDROCELE.  471 

and,  having-  cut  away  the  serous  sac  freely,  have  sutured  its  edges  to 
those  of  the  skin  with  stitches  of  fine  catgut.  But  I  have  gone  farther, 
knowing  how  rebellious  some  hydroceles  are  fp.  468),  and  I  have,  after 
thus  suturing  the  tunica  vaginalis  and  skin,  wiped  over,  once,  and  very 
lightly,  what  is  left  of  the  parietal  layer  of  the  latter  and  the  visceral 
layer  on  the  testicle,  with  silver  nitrate.  1  have  not  found  that  this  has 
been  subsequently  followed  by  orchitis  or  pain. 

Mr.  Lockwood  recommends  that  the  top  of  the  incision  should  be 
a  full  inch  from  the  root  of  the  penis :  that  any  upward  prolongation 
of  the  hydrocele  along  the  cord  should  be  dissected  out  :  that  in  cases 
where  the  origin  is  doubtful,  or  where  the  hydrocele  is  large  and  of 
long  standing,  and  the  testicle  ma}'  be  wasted,  it  is  wise  to  obtain 
permission  beforehand  to  remove  the  testis.  Mr.  Lockwood  finds  it 
easier  to  separate  the  tunica  vaginalis  while  still  distended.  It  is, 
he  believes,  quite  unnecessary  to  paint  the  tunica  vaginalis  vera  with 
chemical  irritants,  or  to  injure  it  mechanically.  On  this  point  readers 
should  refer  to  the  footnote  at  p.  468. 

Instead  of  suturing  the  tunica  vaginalis  (as  above  described)  many 
surgeons  prefer  to  simply  let  the  testicle  drop  back  into  the  scrotum, 
and  to  close  the  skin  wound  in  the  usual  way,  leaving  a  small  drainage- 
tube  in  the  cavity  for  the  first  twenty-four  hours.  Drainage  is  necessary 
here  since  some  oozing  nearly  always  takes  place  into  the  loose  cellular 
tissue,  and  if  an  exit  is  not  provided  for  this  a  large  hfematoma  may 
form.  Immediate  closure  of  the  whole  wound  in  this  way  results  in 
more  rapid  healing  and  earlier  convalescence.  The  sutures  having  been 
introduced,  it  only  remains  to  dust  a  little  iodoform  over  the  wound, 
dry  this  most  scrupulously,  and  apply  the  dressings.  Whatever 
material  is  used  care  must  be  taken  that  the  dressings  should  supply  the 
following  conditions — viz.,  they  must  be  aseptic,  duly  compressive,  and 
unirritating.  I  have  been  in  the  habit  of  using  green  protective  and 
iodoform  gauze,  secured  in  place  by  firm  and  even  bandaging  with  a 
double  spica.  While  this  is  applied,  care  must  be  taken  that  the 
scrotum  is  kept  well  up  on  to  the  pubes.  This  is  a  cardinal  point,  and 
must  be  attended  to  not  only  now,  but  later  on,  at  and  after  each 
dressing.  It  prevents  oedema,  bagging,  and  inflammation,  and  thus 
also  pain,  and  hastens  rapid  repair  of  the  wound.  When  the  dressings 
are  m  situ,  a  pad  of  carbolised  tow  should  be  kept  over  the  anus,  to 
prevent  flatus  or  faeces  contaminating  the  closely  adjacent  wound.  If 
the  skin  incision  has  been  closed,  the  wound  will  be  healed  in  a  week ; 
but  if  Bergmann's  plan  is  adopted,  a  longer  time  will  be  required  for 
this.  On  the  third  or  fourth  day  most  of  the  sutures  uniting  the  skin 
and  tunica  vaginalis  should  be  cut  and  removed ;  by  the  fifth  or  seventh 
day  the  patient  luay  get  on  to  a  sofa,  and  by  a  date  varying  from  the 
fourteenth  to  the  twenty-first  day  he  may  usually  begin  to  get  about, 
with  a  suspender,  and  the  small  remaining  wound  protected  by  a  sealed 
dressing  (some  sal-alembroth  or  iodoform  gauze  sealed  on  with 
collodion)  changed  every  few  days,  or  by  one  of  iodoform  or  resin 
ointment.  As  the  repair  with  aseptic  wounds  is  rapid,  but  often 
filamentous  and  weakly,  I  advise  the  use  of  a  suspender  for  six  months 
or  a  year  after  the  operation,  and  longer  if  occasions  arise  for  hard 
exercise,  such  as  riding,  &c. 


472  OPERATIONS  OX  THE  ABD03IEX. 

VARICOCELE. 

Indications. — While  palliative  treatment  will  be  sufficient  in  the 
great  majority  of  cases,  if.  at  the  same  time,  due  attention  is  paid  to 
the  general  health,  the  occnpation  and  habits  of  the  patient,  and,  where 
this  is  required,  to  his  sexual  hygiene,  an  operation  will  be  justifiable 
in  the  following  cases  : 

(l)  Where  the  patient  is  precluded  from  entering  one  of  the  public 
services,  or  any  occupation  involving  much  activity  in  the  upright 
position.  Thus,  out  of  the  twenty-eight  cases  in  which  I  have  operated, 
twelve  were  private  cases,  of  which  nine  were  applying  and  passed  into 
the  army  and  navy,  and  one  Avas  a  medical  man,  operated  upon  for 
double  varicocele  ;  of  sixteen  hospital  cases,  one  was  desirous  of  entering 
the  police  and  subsequently  did  so  ;  one  was  a  goods-guard  on  probation 
and  found  that  a  large  left-sided  varicocele  threatened  to  spoil  his  pi*os- 
pects,  The  aching  pain,  which  invariabh"  followed  the  jumping  in  and 
out  of  his  brake  van.  being  onh^  relieved  by  the  patient's  lying  down, 
and  being  inevitably  brought  on  again  by  the  next  station.  This  man 
stopped  me  on  London  Bridge  some  five  years  after,  to  say  that  he  was 
in  regular  employment  as  a  goods-guard,  married,  and  the  father  of  two 
children.  Five  others  were  shop  assistants,  and  two  were  gardeners. 
(2)  In  any  case  where  the  varicocele  persists  or  steadily  increases,  in 
spite  of  treatment,  and  where  it  is  accompanied  with  much  distress, 
annoyance  or  pain,  or  where  it  interferes  with  some  justifiable  pursuit, 
such  as  riding;  (3)  where  the  surgeon  has  satisfied  himself  that  the 
testicle  is  undergoing  atrophy ;  (4)  where  the  varicocele  is  accompanied 
by  frequent  seminal  emissions  and  much  mental  misery.  In  the  two 
last  given  indications,  great  caution  must  be  shown  before  operation  is 
resorted  to,  and  the  last  is  the  most  doubtful  of  all.  Where  the  patient 
is  clearly  a  hypochondriac,  or  a  monomaniac  in  genital  matters,  no 
operation  is,  of  course,  to  be  thought  of.     It  is  certain  to  be  a  failure. 

The  choice  of  operation  is  a  very  large  one,  biit  as  I  consider  that  one 
alone  has  been  proved  to  be  alike  efficient  and  simple,  I  shall  not 
occup}-  my  space  with  an  account  of  any  others,  or  with  the  history  of 
the  operation.  Like  so  much  else  in  operative  surgery,  the  only 
efficient  and  simple  operation  for  varicocele  dates  to  the  great  discovery 
of  Lord  Lister.* 

Excision. — This  operation,  pertormed  with  the  parts  well  in  sight. 
has  the  very  great  advantage  of  allowing  the  surgeon  to  carry  out 
each  step  with  precision,  to  include  what  he  thinks  safe,  and  no  more  ; 
it  does  away  with  the  risk  of  transfixing  a  vein,  and  its  possibly 
disastrous  results  of  septic  thrombosis  ;  it  rec[uires  very  few  and  simple 
instruments ;  while  Lord  Lister's  teaching  has  enabled  us  to  perform 
it  without  the  risks  of  hfemorrhage,  cellulitis  and  blood-poisoning, 
which  were  so  terribly  frequent  in  operations  on  veins  performed  before 
his  day. 

For  a  few  days  before,  the  bowels  should  be  kept  well  open,  and  the 
diet  should  be  light  and  limited.  The  parts  should  be  shaved  and 
thoroughl}^  cleansed  with  soap  and  water,  and  then  lotio  hydr.  perch. 


*  Mr.  Howse  drew  attention  to  the  method  of  aseptic  excision  in  varicocele  (^Gin/s 
Ho»p.  Ri']:orts,  1887,  vol.  xxiii.  p.  408). 


VARICOCELE.  473 

I — 4000  (p.  469).  It  is  well  to  perform  the  cleansing  a  few  hours 
before,  and  to  keep  a  compress,  wet  with  the  above  lotion,  on  up  to  the 
time  of  the  operation.  The  patient  having  been  anaesthetised  with 
ether  or  A.C.E.  mixture,  the  vas  deferens  is  isolated,  and  either  kept  so 
by  two  fingers  of  the  left  hand,  or  handed  over  to  an  assistant,  who 
stands  on  the  opposite  side  to  the  surgeon.  In  either  case  the  latter 
makes  the  veins  prominent  by  grasping  the  affected  side  of  the  scrotum 
and  protruding  the  varicocele.  The  skin  incision,  which  should  be  about 
an  inch  and  a  half  long,  may  be  made  in  one  or  two  ways,  either  in  the 
scrotum  directly  over  the  site  of  the  varicocele,  or  above  the  scrotum 
and  in  front,  commencing  at  the  external  abdominal  ring  and  running 
downwards  towards  the  scrotum.  If  the  latter  plan  is  adopted  it  will 
be  found  that  the  varicocele  is  cjuite  easily  pushed  np  into  the  wound, 
and  it  has  the  advantages  of  rendering  the  operation  more  convenient, 
whilst  the  wound  is  more  easily  sutured  and  heals  more  certainly  and 
readily  than  one  which  involves  the  skin  of  the  lower  part  of  the 
scrotum. 

Care  should  be  taken  to  avoid  opening  the  tunica  vaginalis ;  if,  how- 
ever, it  is  opened,  the  opening  shoulcl  be  taken  up  with  Spencer 
Wells's  forceps  and  tied  up  with  fine  catgut,  or  it  may  be  left  without 
treatment.  If  the  wound  runs  an  aseptic  course,  this  complication 
will  give  very  little  trouble.  With  one  or  two  strokes  of  a  keen-edged 
scalpel  the  packet  of  veins  is  exposed  and  is  then  carefully  opened. 
The  surgeon  then  passes  a  steel  director,  first  at  the  upper  and 
then  at  the  lower  angle  of  the  wound  through  the  packet  so  as  to 
leave  about  a  third  of  the  veins  behind  it ;  along  the  director,  which 
thus  keeps  a  track  open  and  easily  found,  an  aneurysm-needle,  or 
eyed-probe,  carrying  a  medium-sized  ligature  of  sterilised  silk,  is 
passed.  This  is  then  tied  firmly  round  the  included  veins.  If  the 
incision  has  been  made  an  inch  and  a  half  long,  and  the  upper  and 
lower  angles  of  the  wound  are  well  retracted,  no  difficulty  will  be 
experienced  in  placing  these  ligatures  near  enough  to  the  external 
abdominal  ring  and  testicle  respectively  to  ensure  removal  of  a  sufficient 
extent  of  the  enlarged  veins.  After  each  of  the  ligatures,  upper  and 
lower,  has  been  tied  securely  and  cut  short,  a  pair  of  scissors  is  run 
along  the  director,  and  the  packet  is  cut  through  about  a  quarter  of  an 
inch  from  each  ligature.  The  portion  of  varicocele  thus  included  is 
then  removed  Ijy  carefully  clipping  it  out  with  a  pair  of  scissors ;  any 
cross  branches  which  may  now  be  divided  are  secured  with  fine  chromic 
gut.  An  extremely  important  step  comes  next.  With  a  sharp-pointed 
half-curved  needle,  carrying  medium-sized  chromic  gut,  the  surgeon 
brings  into  accurate  apposition  the  two  ends  of  the  stumps,  the  ligature 
being  passed  through  the  centre  of  each  stump  close  to  the  correspond- 
ing ligature.  As  it  is  tightened,  an  assistant,  with  a  sharp-pointed 
probe,  brings  the  cut  ends  of  the  veins  on  the  face  of  each  stump 
snugly  and  precisely  together.  The  object  of  this  most  important 
detail  is  to  permanently  shorten  the  cord,  and  to  restore  the  natural 
suspension  of  the  testicle.  It  would  obviously  be  quite  impossible  in 
an}-  subcutaneous  method.  I  have  practised  this  detail  since  1887,  but 
as  Mr.  Bennett  was  the  first  to  draw  attention  to  this  step  (Lancet, 
Feb.  1 891),  the  credit  of  showing  the  importance  of  it  must  be  his.  A 
little  iodoform  having  been  dusted  in,  the  sutured  cord  is  replaced  in 


474  OPERATIOXS  ON  THE  ABDO^HEN. 

the  bottom  of  the  wound.  When  the  skin  is  much  relaxed,  I  finish  the 
operation  by  removing  widely,  by  two  elliptical  incisions,  the  skin  on 
either  side  of  the  small  wound  which  has  been  made,  the  apex  of  the 
incisions  being  placed  well  up  over  the  external  ring.  I  think  it  well  to 
adopt  this  step,  as  I  believe  it  helps  to  brace  up  the  relaxed  parts  ;  but 
it  is  not  of  the  least  use  by  itself,  aud  it  is  much  less  needed  now  if  the 
above-given  precaution  of  ligaturing  together  the  vein-stumps,  and  thus 
shortening  the  cord,  is  taken.  And  the  same  may  be  said  of  another 
step  which  should  be  taken  before  the  close  of  the  operation — i.e., 
ligature  and  removal  of  any  very  enlarged  scrotal  veins,  a  step  Avhich  I 
always  adopt  when  the  patient's  attention  has  dwelt  on  these.  The 
whole  wound,  superficial  and  deep,  is  then  carefully-  scrutinised,  and 
every  bleeding-point  being  secured  is  thoroughly  dried.  The  edges 
of  the  wound  are  then  carefullj^  adjusted  with  silk  or  horsehair 
sutures,  the  tendency  to  inversion  being  borne  in  mind. 

Dressings  of  green  j)rotective  and  iodoform  gauze  are  then  applied, 
due  facilities  being  provided  for  the  patient's  micturition.  In  secur- 
ing the  dressings  in  situ,  care  should  be  taken  to  keep  the  scrotum 
well  up  on  to  the  pubes  by  bringing  the  turns  of  the  spica  from 
below  upwards  and  not  in  the  reverse  direction.  I  generall}'  change 
the  dressings  at  the  end  of  the  third  day,  immediately  after  the 
first  action  of  the  bowels,  and  again  at  the  end  of  the  first  week,  to 
remove  alternate  sutures.  At  this  date  the  patients  may  get  on  to 
a  sofa,  but  I  insist  on  their  maintaining  the  recumbent  position  for  two 
or  three  weeks.  Aseptic  union,  forming  quickly  and  without  the 
medium  of  granulations,  remains  weak  for  a  long  time.  If  the  stumps 
of  the  cord  have  been  sutured  together  there  is  much  less  need  for  the 
patient  to  wear  a  suspender  afterwards ;  but  to  give  the  operation  every 
chance,  and  to  save  all  drag  and  tax  upon  parts  which  have  very 
recently  united,  I  generally  advise  that  a  suspender  be  worn  for  three 
months.  In  addition  to  the  supjDort  which  I  believe  to  be  advisable 
while  the  sutured  stumps  of  the  cord  are  being  firmly  knit  together, 
I  am  of  opinion  that  the  continuance  of  support  to  the  parts  for  a  while 
prevents  a  too  rapid  melting  away  of  the  little  nodular  mass,  which, 
callus-like,  marks  the  seat  of  the  operation. 

The  points  to  which  I  attach  most  importance  in  the  operation  are 
maintenance  of  strict  asepsis  throughout,  suturing  together  the  two 
stumps,  and  so  shortening  the  cord  and  providing  for  suspension  of  the 
testicle  ;  arrest  of  all  hagniorrhage,  thorough  drying  out  of  the  wound, 
the  use  of  a  horsehair  di"ain  if  the  parts  have  been  much  disturbed,  and 
the  careful  application  of  an  antiseptic  dressing,  so  as  to  keep  the 
scrotum  well  up  on  to  the  pubes.  I  look  upon  these  details  as  most 
necessary  if  rapid  healing  is  to  be  made  certain  of,  and  cellulitis, 
epididymo-orchitis,  and  hj'drocele  prevented. 

Mr.  Bennett  (loc.  supra  cit.),  in  his  operation  for  varicocele,  advocates 
some  different  and,  in  two  instances,  far  more  radical  steps  ;  thus  (a), 
he  does  not  open  the  general  sheath  immediately  surrounding  the  veins, 
as  by  leaving  it  intact  he  makes  certain  of  passing  the  ligature  around 
all  the  affected  veins,  as  none  of  these  ever  lie  outside  the  fascia. 
Furthermore,  the  fascia,  if  not  opened,  better  carries  the  weight*  of  the 

*  This  is  rendered  of  less  importance  by  the  suture  which  unites  the  vein  stumps. 


VAEICOCELE.  475 

dependent  testicle.  (/3)  Mr.  Bennett  considers  that  the  view  generally 
held  that  the  spermatic  artery  is  displaced  with  the  vas  deferens,  and 
thus  kept  out  of  the  way,  is  a  mistake  ;  in  reality  the  artery  remains 
with  the  veins.  Furthermore.  Mr.  Bennett  holds  that  the  artery  is 
usually  and  may  always  be  safely  divided  with  the  veins,  for  as  long  as 
the  wound  remains  aseptic  the  artery  to  the  vas  deferens,  "  and  some 
outlying  branches  of  the  spermatic  artery,  one  of  which  sometimes 
comes  off  high  up  and  so  may  easity  escape  division,  are  sufficient  to 
carry  on  the  blood  supply  to  the  testicle,  and  to  prevent  any  risk  of 
atrophy." 

While  Mr.  Bennett's  plan  is  justified  by  the  results  obtained  by  his 
•own  practised  hands,  I  feel  that,  writing  as  I  am  for  those  who  may  not 
have  had  many  opportunities  of  operating  for  varicocele,  I  ought  to  ])oint 
■out  certain  grave  risks  which  I  consider  to  be  at  least  possible,  if  the 
above  teaching  is  widely  followed. 

First,  as  to  division  of  all  the  veins,  i  will  say  at  once  that  perhaps  I 
am  prejudiced  unduly  by  the  unfortunate  result  of  one  case,  which  I 
mention  below.  While  I  admit  that  recurrence  of  the  varicocele  may  be 
brought  about  hx  removal  of  too  few  of  the  veins,  I  feel  strongly  that 
inclusion  of  all  of  them  in  the  ligature  involves  a  much  graver  risk. 
Further,  I  cannot  agree  with  Mr.  Bennett  that  it  is  safe  to  trust  to  the 
artery  of  the  vas,  or  branches  of  the  spermatic  \^^hich  may  come  off 
sufficiently  high  up  to  be  available,  and  some  small  unimportant  anas- 
tomotic branches  passing  from  the  sub-vaginal  tissue.  Mr.  Bennett 
allows  that  these  vessels  are  small  and  delicate,  and  points  out  that  any 
inflammation  about  the  parts  may  be  sufficient  to  choke  them,  sloughing 
or  wasting  of  the  organ  following  as  a  necessary  result. 

Thus,  while  in  no  way  criticising  Mr.  Bennett's  modifications  of  the 
operation  when  practised  by  himself,  I  strongly  advise  my  junior 
readers  to  make  use  of  the  simpler  and  very  efficient  method  given  at 
p.  472. 

The  chief  risks  and  causes  of  failure  in  the  operation  are  as 
follows : — 

I.  Sepsis  and  its  Results. — The  risk  of  these  was  always  present 
■with  the  old  subcutaneous  operations,  however  modified ;  it  is  by  no 
means  to  be  lost  sight  of  with  the  open  operation  performed  with  the 
advantages  of  modern  surgery.  A  good  instance  of  sepsis  and  its 
dangers  is  recorded  by  Mr.  H.  Lee  {Clin.  Soc.  Trans.,  vol.  i.  p.  73). 
Here  erj'sipelas,  repeated  haemorrhages,  sloughing  of  the  skin  of  the 
scrotum  and  penis,  and  multiple  abscesses,  followed  on  Mr.  Lee's 
operation  of  subcutaneous  division  of  the  veins  between  two  pins  secured 
with  figure-of-eight  sutures.  Mr.  Lee  also  mentioned  cases  in  which 
abscesses,  localised  sloughing  of  the  skin,  and,  on  two  or  three  occasions, 
arterial  ha3morrhage,  controlled  by  introducing  a  third  pin,  had  happened 
in  his  experienced  hands.  It  is  certain  that  other  operators  have  not 
been  so  candid. 

II.  Inclusion  of  too  many  Veins. — That  this  is  a  real  danger  is 
shown  by  a  case  of  mine  which  I  published  (St/st.  of  Sun/.,  vol.  iii., 
p.  571).  The  patient  here  had  a  double  varicocele,  that  on  the  left  side 
being  truly  colossal.  It  was  my  third  case,  and  was  operated  on  with 
precisely  the  same  precautions  as  to  the  vas  and  to  the  maintenance  of 
asepsis  as  those  given  above  (p.  472),  save  that  the  carbolic  spray  was 


4/6  OPERATIONS  ON  THE  ABDO]VIEN. 

used  instead  of  irrigation.  Owing  to  the  huge  size  of  the  varicocele 
three  bundles  of  veins  were  removed,  and  even  then  a  large  number 
appeared  to  be  left,  the  varicocele  being  a  quarter  of  its  former  size. 
The  case  did  well  up  to  the  eighth  day,  when  the  wound  opened,  and  the 
lower  half  of  the  testis,  evidently  gangrenous,  presented  itself.  This 
was  cut  away  after  the  application  of  a  chromic  gut  ligature.  Though, 
at  the  close  of  the  operation,  it  did  not  appear  that  too  many  veins  had 
been  removed,  such  must  have  been  the  case.  I  am  certain  no  injury 
was  inflicted  upon  the  vas  deferens ;  throughout  the  operation  this  was 
entrusted  to  very  careful  hands,  those  of  Dr.  B.  N.  Rake,  at  that  time 
my  dresser,  lately  of  Trinidad,  and  one  of  our  chief  authorities  on 
lepros}".  whose  untimely  death  has  cut  short  so  much  excellent  work. 

III.  Recurrence  of  the  Varicocele. — 1  am  of  opinion  that  if  operation- 
cases  were  more  thoroughly  followed  up  afterwards,  this  secjuela  would 
be  found  to  be  more  common  than  is  thought  to  be  the  case.  It  is 
especially  likely  to  follow  the  subcutaneous  method,  where  the  patient 
is  allowed  to  get  up,  or  is  hurried  out  of  the  hospital  to  make  room  for 
another  case  as  soon  as  the  wound  is  healed.  To  prevent  this  risk  of 
recurrence  Mr.  Bennett  lays  stress  on  the  need  of  removing  the  entire 
plexus  of  spermatic  veins.  As  I  have  been  unfortunate  enough  to  meet 
with  a  case  in  which,  in  spite  of  care  taken,  too  many  veins  were 
ligatured  and  removed,  I  cannot  agree  with  Mr.  Bennett  (p.  475). 
Another  instance  of  what  appears  to  be  recurrence,  but  which  is  really 
an  escape  of  the  upper  part  of  the  spermatic  plexus,  may  be  due  to  the 
upper  ligature  being  applied  too  low  down  (Bennett).  In  this  case  the 
part  of  the  plexus  between  the  upper  ligature  and  the  external  ring 
remains  full,  and  may  give  trouble  for  a  time,  though  it  gi'adually 
shrinks. 

Insecure  knotting  of  the  ligature,  or  not  using  reliable  material,* 
may.  of  course,  lead  to  recurrence  after  any  method  in  Avhich  ligatures 
are  used  but  the  veins  are  not  also  divided. 

CASTRATION  (Fig.    1 91). 
Indications. 

1.   Groirths  of  the  Testicle. 

Diagnosis  of  Malignant  Disease  of  the  Testis. — As  the  records  of 
STU'gery  contain  many  instances  of  mistakes  under  able  hands — haema- 
toceles  removed  for  malignant  disease,  and  malignant  disease  opened, 
for  hematocele,  a  few  hints  ma}^  not  be  out  of  place  here  on  the  subject 
of  castration. 

Centra-indications. — Castration  should  not  be  performed  when  the 
cord  is  extensively  involved;  when  masses  can  be  felt  deep-seated  in 
the  iliac  fossa  and  lumbar  region ;  when  there  is  any  evidence  that  the 
liver  or  lungs  are  involved ;  or  when  the  jaundiced  sallow  tint  and 
rapid  emaciation  point  to  the  disease  having  become  general.  In  cases 
at  all  advanced,  though  the  patient  might  be  rid  of  an  encumbrance, 
the  operation  Avould  be  very  liable  to  be  followed  by  a  low  foi'm  of 
peritonitis,  or,  before  the  wound  was  healed,  swelling  would  probably 
appear  in  the  inguinal  region,  and  the  growth  soon  fiingate  through 
the  wound. 


Jlr.  Bennett  prefers  kangaroo-tail  tendon  ligatures. 


CASTRATION.  477 

The  following  are  the  points  on  which  most  reliance  may  be  placed : 

Continuous,  and  often  quickly  progTes>ing  solid  enlargement  of  the 
testicle  or  epididymis  without  inflammation.  Sometimes  this  progress 
,  is  much  slower  :  occasionally  it  may  seem  to  be  in  abeyance,  but  careful 
watching  with  frequent  examinations  fand  these  are  the  key  to  obscure 
cases)  will  show  that  the  enlargement  is  progressing  in  spite  of  treat- 
ment. Failure  of  well-directed  treatment :  where  the  swelling  is  small, 
still  oval  in  shape,  and  smooth  and  firm  in  outline,  a  brief  trial  of 
mercury  or  potassium  iodide  may  be  made,  combined  with  carefully 
applied  Leslie's  strapping,  but  where  in  a  week  there  is  no  result,  or 
where  the  case  is  of  longer  duration,  and  delay  ^vill  very  likely  be  fatal, 
an  exploratory  incision  with  antiseptic  precautions,  followed,  if  need  be, 
by  immediate  castration,  will  be  the  wiser  course.*  Consistence. — This 
is  rarely  for  long  the  same  all  over  the  swelling.  Even  if  a  firm,  slow 
growth  seem  uniform  and  recall  orchitis,  a  careful  examination  will 
usually  find  one  or  two  spots  which  are  more  elastic  than  the  rest. 
Usually  the  softening  at  places  where  cystic  or  degenerative  changes 
are  taking  place  is  well  marked.  But  it  may  require  somewhat 
prolonged  watching  to  detect  one  or  two  at  first  lowly  rising  projections 
or  bosses  which  foretell  that  the  tunica  albuginea  is  becoming  thinned 
at  this  spot.  Of  enlargement  of  the  cord.'f'  fulness  of  the  scrotal  veins, 
adhesion  of  the  scrotal  tunics,  increasing  aches  and  painfulness  I  say 
nothing,  as  they  are  evidence  that  the  disease  is  entering  into  a 
later  stage. 

An  exploratory  incision  is  to  be  preferred  to  the  use  of  a  trocar,  as 
being  more  certain  to  give  information. 

A  trocar  may  enter  a  solid  part  or  withdraw  some  scanty  mucoid 
fluid.  Sometimes  the  amount  of  blood  which  flows  through  the  cannula 
of  a  trocar  thrust  into  a  testicle,  the  subject  of  rapidly  growing 
malignant  disease,  is  so  great  as  to  lead  to  the  supposition  that  it  must 
be  a  hsematocele.  In  such  cases,  however,  the  diminution  of  the 
swelling  is  not  so  proportionate  to  the  flow  of  blood  as  it  would  be  in 
ha^matocele.  Furthermore,  the  blood  is  usually  bright,  not  dark  and 
altered  as  in  hfematoceles. 

Prognosis. — It  will  be  seen  that  the  prognosis  is  always  grave, 
extremely  so  in  the  softer  and  more  rapid  gro^^'ths.  Kocher  goes  so  far 
as  to  say  with  regard  to  these  that  no  case  of  really  permanent  cure  of 
encephaloid  carcinoma  is  known.  In  medullary  sarcomata,  especially  in 
children,  the  prognosis  is  almost  as  gloomy.  But  while  the  above 
opinion  is  only  too  true  of  the  majority  of  cases,  a  sufficient  number 
have  been  recorded  to  show  the  benefit  which  may  follow  on  castration, 
even  in  the  soft  forms  of  sarcomata. 

Mr.  Meade,  of  Bradford,  removed,  in  1846,  the  testicle  of  a  patient,  aged  40,  for  a 
swelling  which  had  lasted  about  nine  months  (^Lond.  Med.  Gaz..  vol.  xliv.  p.  702). 
Nine  years  later,  the  patient  remained  free  from  any  return  of  the  disease.  In  the 
Museum  of  St.  George's  Hospital  is  a  specimen  of  a  testicle  converted  into  a  mass  of 
soft  malignant   growth,  with  large   caseating  patches,  which   Mr.   Caesar   Hawkins 

*  I  may  warn  my  younger  readers  of  the  temporary  improvement  which  potassium 
iodide  sometimes  seems  to  bring  about  even  in  malignant  swellings. 

t  I  quite  agree  with  Mr.  Butlin  (Joe.  supra  eit.^  that  early  enlargement  of  the  cord 
is  met  with  in  inflammatory  conditions  of  the  testicle,  and  is.  here,  a  contra-indication 
to  malignant  disease. 


478  OPEEATIONS  ON  TIIE  ABDOMEN. 

removed  from  a  patient,  aged  45.  the  enlargement  having  lasted  two  years.  Twelve 
years  later  this  patient  was  alive,  and  in  good  health.  In  the  Med.  Times  and 
6az.,  1886.  vol.  ii.  p.  28j.a  case  of  Mr.  Cock's  is  mentioned  in  which  a  patient  remained 
in  good  health  for  six  years  after  castration  for  '•  medullary  cancer."  being  then  lost 
sight  of  in  consequence  of  his  emigration  to  Australia. 

While  these  cases  are  most  encouraging.  I  fear  they  are  exceptional. 
It  will  be  noticed  that  in  one  a  swelling  had  lasted  nine  months,  and  in 
another  two  years.  If  it  be  thought  that  such  cases  show  that  no  limit 
can  be  fixed  beyond  which  castration  must  be  useless,  the  following 
must  be  remembered.  First,  is  it  possible  that  the  earlier  enlargement 
was,  for  some  time  at  least,  inflammatory  ?  Secondly",  as  a  rule,  in  the 
softer  sarcomata,  enlargement  of  the  lumbar  glands  will  be  present  by 
the  end  of  the  first  year  of  the  growth,  and  often  earlier. 

As  a  rule,  the  retro-peritoneal  glands  and  viscera  will  be  involved  by 
extension  and  secondaiy  deposits  within  six  months  of  the  time  of 
castration.  And  this  result  is  the  more  disappointing  because  the 
testicle,  a  free,  floating  organ,  and  one  placed  independently  in  a  fibrous 
capsule,  appears  to  be  remarkably  favourably  placed  for  the  radical 
removal  of  malignant  disease.  The  intimate  association  of  the  organ 
with  the  lymphatic  system,  both  within  itself  and  with  those  within  the 
abdomen,  and  the  facility  with  which  these  are  early  implicated, 
handicap  us  terriblj"  here. 

But  if,  as  happens  most  frequently,  the  disease  recurs  elsewhere  after 
castration,  a  useful  life  may  yet  be  prolonged,  the  patient,  rid  of  a 
wearisome  encumbrance,  is  made  more  comfortable,  and  towards  the  close, 
death  from  internal  deposits  of  malignant  disease  is  not  accompanied 
with  the  same  distress  both  to  the  patient  and  those  around  him  as  when 
the  disease  is  situated  externally.  In  proof  of  the  temporary  benefit  of 
castration,  Mr.  Curling  (Diseases  0/  the  Testis,  p.  342)  relates  the  case  of 
an  eminent  barrister,  who,  for  two  years  and  a  half  after  the  removal  of 
a  testicle  for  soft  cancer,  was  able  to  continue  the  practice  of  his  profes- 
sion to  the  great  advantage  of  his  family,  death  ultimately  taking  place 
from  extension  to  the  lumbar  glands. 

II.  Ttiherallar  Testicle. — I  am  of  opinion  that  castration  should  be 
performed  much  earlier  in  this  disease  than  is  usually  the  practice. 
Natural  cures  are  so  few,  dissemination  is  so  frequent  and  so  grave, 
whether  to  bladder  and  kidneys,  vesicular  seminales,  or  prostate,  or  to  the 
lungs,  while,  on  the  other  hand,  castration  is  nowadaj^s  so  safe  an  opera- 
tion, that  it  should  not  be  deferred. 

Early  phthisis  should  not  interfere  with  removal  of  a  tubercular  testis 
which  resists  treatment  and  prevents  the  patient  getting  open-air 
exercise,  and  weakens  his  health  by  discharge.  Owing  to  the  condition 
of  the  lungs,  chloroform  should  be  here  given,  instead  of  ether. 

Tubercular  disease  of  the  prostate  is  a  sovirce,  usually,  of  such  extreme 
misery,  that  any  existing  cause  in  the  testis  should  be  removed  very 
early.  Moreover,  from  what  we  have  learnt  from  castration  in  enlarged 
prostate  (p.  479),  removal  of  tubercular  testes  may  prevent  or  greatly 
delay  deposit  of  tubercle  in  the  prostate. 

I  have  only  space  to  mention  briefly  the  indications:  (i)  Where 
erasion  fails  in  lesions  still  limited  to  the  epididymis.  If  one  or  more 
discharging  fistulas  still  persist  here,  especially  if  the  patient  is  not  in  a 
position  to  avail  himself  of  a  repetition  of  erasion  at  the  seaside,  castra- 


CASTRATION.  479 

tioii  should  be  perfornied.  slio-ht  as  the  mischief  appears  to  be,  especially 
if  they  affect  the  patient's  health  or  interfere  witli  the  outdoor  exercise 
so  necessary  in  these  cases.  It  is  only  too  probable  that  minute  deposits 
are  already  making  their  way  into  the  testicle  itself  by  spreading  along 
the  rete,  a  condition  impossible  to  recognise  by  external  manipulation. 
(2)  Where  after  erasion  any  fistula  has  healed,  but  careful  watching  of 
the  patient,  always  to  be  insisted  on,  detects  the  existence  of,  it  may  be 
slight  but  persistent  swelling  in  the  scrotum,  with  night  sweats  and  loss 
of  flesh.  These  may  point  to  mischief  in  the  remains  of  the  sexual  gland, 
and  not  necessarily  to  disease  in  the  prostate,  &c..  or  in  the  lungs.  (3) 
Where  the  body  of  the  testicle  is  involved.  When  this  remains  enlarged, 
and  liable  to  attacks  of  inflammation,  castration  should  be  performed. 
(4)  Where  the  testicle  remains  atrophied  and  riddled  with  fistulae,  one  or 
more  of  which  persist  in  discharging,  removal  of  a  useless  and  dangerous 
organ  should  be  practised.  (5)  When  a  hydrocele*  is  present,  especially 
if  purulent. 

III.  SypJdlitic  Testis. — Here,  owing  to  the  specifics  which  we  possess. 
casti'ation  is  much  more  rarely  called  for.  The  indications  can  readily 
be  judged  of  from  those  above  given. 

IV.  Old  H(einatocele. 

TiidAcations. — Failure  of  previous  treatment,  especially  in  a  man  of 
middle  life  whose  activity — e.ij.,  in  riding— is  much  interfered  with. 

The  frequency  with  which  malignant  disease  follows  on  repeated  injury 
and  irritation  of  the  testicle  is  well  knowii  (Rindfleisch,  Paih.  Hist.. 
vol.  ii.  p.  197). 

v.  Retained  Testis. 

Indications. —  i.  When  such  a  testis  is  the  seat  of  malignant  disease. 
2.  When  it  seriously  cripples  the  patient  by  the  recurrent  attacks  of 
inflammation  associated  with  it.  3.  When  a  co-existing  hernia  cannot 
be  kept  up  by  a  truss,  owing  to  the  presence  of  the  testis. 

VI.  Enlarged  Prostate. 

This  operation  has  of  late  years  been  much  resorted  to.  chiefly  through 
the  work  done  by  Prof.  J.  William  Wliite.'''  of  Philadelphia  (.4?i?*.  ot 
Surg.,  1893,  and  July  1895). 

The  following  are  the  chief  of  Prof.  White's  conclusions  : 

(i)  Clinical  experience  shows  that  in  a  very  large  proportion  of  cases 
(87  per  cent.)  rapid  atrophy  of  the  prostatic  enlargement  follows  the 
operation,  and  that  disappearance  or  great  lessening  of  long-standing 
cystitis  (52  per  cent.),  more  or  less  return  of  vesical  contractility  (66  per 
cent.),  amelioration  of  the  most  troublesome  symptoms  (83  per  cent.), 
and  a  return  to  local  conditions  not  far  removed  from  normal  (46  per 
cent.),  may  be  expected  in  a  considerable  number  of  cases. 

(ii.)  The  mortality  is  18  per  cent.  If  patients  are  operated  upon 
under  surgically  favourable  conditions — i.e.,  before  the  actual  onset  of 
uraemia,  or  before  the  kidneys  have  become  disorganised  by  backward 

*  On  the  subject  of  tubercular  hydrocele,  of  the  influeace  of  co-existing  disease  in 
the  vesiculje  seminales,  prostate,  and  lungs,  on  castration,  I  must  refer  my  readers  to 
chapter  vi.  of  TJic  Uiseasea  of  the  Male  Organ-^  of  Generation. 

t  Ramm,  of  Christiania.  seems  to  have  been  the  first  to  perform  the  operation  (Centr. 
f.  Chir.,  Sept.  2,  1893),  ^^^^  it  is  to  Dr.  White  that  our  profession  is  indebted  for 
first  collecting  and  publishing  with  unmistakable  clearness  the  evidence,  clinical, 
pathological  and  experimental,  which  would  justify  a  resort  to  this  operation. 


48o  OPERATIONS  ON  THE  ABDOMEN. 

pressure  and  infection — Prof.  White  thinks  that  the  mortality  will  be 
onlj'^  7"  I  per  cent.  The  following  appear  to  be  some  of  the  chief  causes 
of  a  fatal  issue,  (i)  Sepsis.  This  is  very  likely  when  it  is  difficult  to 
prevent  occasional  dribbling  of  urine.  (2)  When  mania  or  mental 
aberration  follows.  As  this  has  followed  in  a  small  proportion  of  cases 
it  must  always  be  reckoned  with.  (3)  Resiilts  of  kidney  failure,  a 
complication  always  present  in  these  cases,  and  especialh"  to  be  feared 
when  the  operation  is  called  for  in  long-standing  and  advanced  cases  of 
enlarged  prostate.  In  such,  the  operation  will  be  considered  b}^  the 
friends  to  be  the  actual  cause  of  death  ;  in  reality  it  merely  fails  to  save 
life.*  (4)  Causes  of  death,  common  to  any  operation  performed  in  the 
aged,  such  as  hemiplegia,  and  cardiac  failure. 

(iii.)  Comparison  with  other  operative  procedures.  Compared  with 
prostatectomy,  the  very  much  smaller  risk,  the  greater  simplicity,  ease, 
and  quickness  of  castration,  the  far  smaller  amount  of  anjBsthetic,  are 
too  obvious  advantages  of  castration  to  need  more  than  mention.  As 
to  drainage,  castration  does  away  with  the  inconveniences  of  any  fistula, 
and  the  noisome  leakage  which  ma_v  be  inseparable  from  it.  On  the  other 
hand  is  the  repugnance  which  so  many  men,  even  when  well  on  in  life, 
feel  towards  parting  with  their  testicles,  a  repugnance  which  we 
shall  often  have  to  meet,  and  which  will  frequently  baffle  us,  but  one  for 
which  the  patient  alone  must  be  responsible,  when  it  has  been  clearly 
put  before  him  how,  having  advancing  enlargement  of  the  prostate,  he 
stands  on  the  brink  of  a  i)recipice,  and  that  it  requires  very  little  indeed 
to  send  him  over. 

fiv.)  As  to  unilateral  castration,  Dr.  White  considered  the  evidence 
contradictory,  and  the  operation  worthy  of  further  investigation.  There 
is  no  doubt  that  in  some  cases  it  has  been  followed  by  unilateral 
atrophy  of  the  prostate,  and  in  two  cases  at  least  by  very  marked 
improvement  of  symptoms. 

(v.)  As  to  ligature  or  division  of  the  vasa  deferentia.  Dr.  White's 
experiments  on  dogs  have  shown  that  in  nearly  every  case  there  was 
commencing  and  considerable  loss  of  weight  of  the  prostate.  These 
results  appear  anomalous  and  require  confirmation. 

(vi.)  Ligature  of  the  vascular  constituents  of  the  cord,  or  of  the  whole 
cord,  produces  atrophy  of  the  prostate  ;  but  in  Dr.  White's  experiments 
only  after  first  causing  disorganisation  of  the  testes. 

The  above  conclusions  have  been  to  a  large  extent  justified,  although 
in  the  light  of  more  recent  experience  they  should  be  to  some  extent 
modified. 

Owing  to  the  more  careful  selection  of  patients  the  mortality  has  been 
decidedly  diminished.  In  a  collection  of  159  cases  by  Dr.  Alfred  C. 
Wood  (Aw/i.  of  tSurg.,  September  1900)  the  mortality  was  8  per  cent.,  or 
10  per  cent,  less  than  in  Prof.  White's  list.  This  is  practically  the 
reduction  in  mortality  that  Prof.  White  predicted. 

Although  some  degree  of  improvement  has  taken  place  in  most  of  the 
cases  (over  90  per  cent.,  according  to  Wood's  tables)  the  actual  amount 


*  In  Mr.  H.  Fenwick's  words  QMcd.  Ann.,  1896,  p.  508).  '•  There  is  every  reason  to 
believe  that  unsuitable  and  unfavourable  cases  have  been  chosen  in  the  first  wild  rush 
which  is  so  unreasonably  made  at  every  innovation.  Urajniic  and  even  dying  patients 
have  been  castrated." 


CASTE  ATIOX.  481 

of  benefit  has  not  been  perhaps  so  great  as  would  be  expected  from 
Prof.  White's  conclusions  ;  it  has,  nevertheless,  been  sufficient  to  place 
this  method  of  treatment  on  a  sound  basis. 

The  cases  in  which,  in  my  opinion,  the  operation  is  most  called  for, 
fall  into  two  groups.  (A)  The  more  argent.  Where  (i)  previous  appro- 
priate treatment,  carefully  carried  out,  has  failed  ;  (2)  where  there  have 
been  one  or  more  attacks  of  retention  ;  or  (3)  where  hfemorrhage  has 
taken  place.  In  either  case  the  peril  of  cystitis,  too  often  fatal  here,  is 
enormously  increased  :  (4)  Where  there  is  inability  to  micturate,  or 
where  this  is  painful  and  frequent;  (5)  where  the  passage  of  the 
catheter  is  increasingly  difficult  with  the  risks  of  hemorrhage,  formation 
of  false  passages,  &c.  ;  (6)  where  the  prostate  is  soft  and  elastic,  not 
densel_y  hard  and  fibrous — in  such  cases  marked  relief  may  be  expected. 
Of  course,  the  greater  the  power  of  voluntary  micturition  which  remains, 
the  more  natural  the  urine  as  to  urea,  sp.  gr.,  albumen,  and  sugar,  the 
greater  the  rallying  power  of  the  patient,  and  the  clearer  the  mind  the 
better  the  prognosis.  (B)  Less  urgent  cases.  Here  the  operation  is 
prospective  and  preventive.  The  patient  is  younger,  the  power  of 
voluntary  micturition  is  still  good,  there  is  no  cystitis,  but  palliative 
treatment  fails  to  relieve  the  frequent  disturbances  at  night,  and 
hgematuria  has  begun  to  occur  at  intervals.  Here  the  surgeon  is 
abundantly  justified  in  advising  the  operation  as  a  preventive  of  worse 
things  which  are  certain  to  come.  The  operation  will  not  be  often 
accepted  here,  but  it  is  in  such  cases  that  it  will  give  the  best 
results. 

As  to  the  amount  of  relief  which  we  can  promise  our  patients,  we 
shall  do  well  to  be  cautious  while  hopeful,  deciding  each  case  by  itself 
very  carefulh',  especially  as  regards  these  two  factors,  (a)  the  amount 
of  voluntary  micturition  and  control  which  this  operation  will  restore 
must  largely  depend  upon  the  condition  of  the  bladder,  how  far  long- 
standing cystitis  or  habitual  use  of  the  catheter  has  damaged  its  walls, 
replacing  the  muscular  by  fibrous  tissue,  and  converting  it  into  an 
inelastic  thick-walled  sac.  (^)  The  state  of  the  prostate.  The  more 
vascular,  the  softer,  the  more  rich  in  glandular  tissue  this  is,  the  more 
decided  will  be  the  shi'inking  that  follows  castratioTi.  On  the  other 
hand,  the  denser  and  more  fibrous  the  gland,  the  longer  delayed 
certainly,  and,  probably,  the  less  marked  will  be  the  benefit.  It 
should  be  remembered  also,  as  pointed  out  by  Albarran.  that  six  or 
twelve  months  may  elapse  before  the  full  benefit  is  attained,  accord- 
ing to  the  condition  of  the  prostate. 

Operation. — I  have  nothing  to  add  to  the  account  fully  given  below, 
save  that  both  testicles  should  be  removed  through  one  incision  in  the 
scrotal  raphe.  As  soon  as  the  superficial  fascia  is  divided,  cutting  a 
little  to  each  side  will  admit  of  each  testicle  being  shelled  out.  Each 
cord  should  be  divided  immediately  above  the  testicle,  and  the  whole 
operation  conducted  with  as  little  disturbance  of  the  parts  as  possible. 
This  method  leaves  only  one  wound  to  heal,  a  point  of  some  importance 
in  broken-down  patients,  \vhere  the  feeble  mental  power  may  lead  to 
restlessness,  disturbance  of  the  dressings,  sepsis,  &c.  In  those  cases 
where  there  is  dribbling  of  urine  and  the  scrotum  is  liable  to  be  wet, 
the  usual  incision  should  be  made  on  one  side,  and  both  testicles 
removed  through  this  wound.  The  patient  should  then  be  turned  on  to 
VOL.   II.  ^I 


482 


OPERATIONS  ON  TIIE  ABDOMEN. 


his  other  side,  so  that  the  penis  hangs  away  from  the  wonnd,  and  the 
dressings  well  protected  with  jaconet. 

Much  rarer  indications  are : — VII.  Insanity,  chronic  epilepsy,  &c.,  Jcept 
tip  by  onanism*  VIII.  Injury.  IX.  The  radical  cure  of  hernia — i.e., 
when  the  operation  cannot  be  completed  without  removal  of  the  testis, 
owing  to  the  firm  adhesions  of  the  sac  to  the  cord,  especially  when  this 
occurs  in  a  patient  approaching  middle-age.  It  is  always  well,  here,  to 
obtain  leave  for  castration. 

Operation  (Fig.  191). — The  absence  of  any  hernia  on  the  side 
operated  on  having  been  ascertained,  and  the  parts  duly  shaved  and 
cleansed,  the  surgeon  protrudes  the  testicle  with  his  left  hand  so  as  to 
make  the  overlying  tissues  tense,  and  divides  them  from  the  external 
abdominal  ring,  prolonging  his  incision  as  required,  so  as  to  ensure 
free    and    easy  drainage.      In  cases  where  the  skin  is  involved   by  a 


Fig.   191. t 


growth,  ulcerated  by  a  hernia  testis,  or  invaded  by  tubercle,  two- 
elliptical  incisions  should  be  made,  well  wide  of  the  disease,  and 
meeting  above  and  below.  The  first  incision  having  exposed  the  cord 
above,  this  is  defined,  and  the  scrotal  tunics  are  quickly  shelled  off  with 
the  right  hand,  while  the  testis  is  still  further  protruded  with  the  left.| 
The  spermatic  cord  is  now  isolated  as  high  as  may  be  needful,  the 
inguinal  canal  being  carefully  opened  upon  a  director,  if  this  is 
necessary  to  get  above  the  disease.  An  aneurysm-needle,  threaded  with 
a  double  ligature  of  aseptic  silk  or  stout  chromic  gut,  is  passed  through 


*  On  these  subjects  I  may  refer  my  readers  to  chapter  xii.  p.  477  of  Diseases  of  the 
Mali'  Organs  of  Generation. 

f  In  malignant  disease  the  incision  should  be  carried  up  much  higher  into  the  groin 
and  the  cord  tied  close  to  the  internal  ring.  To  prevent  a  hernia  the  layers  should  be 
sutured  according  to  the  directions  given  at  p.  202. 

%  There  is  often  an  adhesion  below,  between  the  testis  and  the  fundus  of  the 
scrotum  (Fig.  191).    This  represents,  according  to  some,  the  remains  of  the  mesorchium.- 


ORCHIDOPEXY.  485 

the  cord,  the  loop  of  the  ligature  cut,  the  needle  Avithdrawn,  and,  the  cord 
having  been  tied  in  two  halves,  the  ends  of  one  ligature  are  cut  short, 
while  those  of  the  other  are  tied  round  the  whole  cord  to  ensure  that  no 
vessel  escapes.  The  ends  of  this  also  are  then  cut  short.  The  ligatures 
being  thus  embedded  in  the  cord  substance,  there  is  no  risk  of  their  slip- 
ping, and  if  they  be  tied  as  tightly  as  possible  (by  looping  the  ligatures 
round  two  pairs  of  scissors  or  forceps),  there  is  no  danger  of  after- 
suffering.  Other  methods  consist  in  securing  the  vessels  alone,  singly, 
by  torsion,  or  by  chromic  gut,  or  by  fixing  the  cord  in  the  upper  angle 
of  the  w^ound  with  a  clamp.  The  mode  of  ligature  above  given  is  much 
more  speedy  and  also,  I  am  certain,  perfectly  efficient.  Securing  each 
vessel  is  tedious,  as  it  is  needful  to  make  sure  of  every  one,  even  when 
they  are  not  enlarged,  a  condition  not  infrequent  in  growths.  If  any 
of  the  arteries  are  left  unsecured,  dangerous  bleeding,  when  the  cord 
retracts  upwards,  calling  for  laying  open  of  the  canal,  is  very  probable. 

The  cord,  having  been  secured,  is  severed  at  least  an  inch  above  the 
disease,  and  the  mass  removed.  The  wound  is  then  examined  in  the 
case  of  a  soft,  rapid  growth,  and  where  a  tubercular  testis  has  threatened 
to  fungate,  any  suspicious  skin  must  be  clipped  away,  and  a  sharp  spoon 
freely  used. 

A  few  scrotal  vessels,  notably  one  in  the  septum,  may  require  securing. 
The  wound  is  then  closed  with  carbolised  silk  and  horsehair,  pains  being 
taken  to  meet  the  tendency  of  the  scrotal  edges  to  invert. 

Every  precaution  should  be  taken  during  and  after  the  operation 
to  promote  rapid  healing,  especially  in  hospital  practice.  Patients  who 
have  to  submit  to  castration  are  often  reduced  in  health,  and  are  thus 
liable  to  erysipelas,  and  in  cases  which  become  septic  a  low  form  of 
peritonitis  is  very  likely  to  follow,  especially  if  the  canal  has  been 
opened  up  ;  moreover,  septic  thrombosis  may  easily  follow  a  wound 
made  in  a  region  so  abounding  in  lymphatics  and  loose  celbalar  tissue. 


ORCHIDOPEXY. 

The  following  account  of  this  operation  is  extracted  from  that  given 
in  Diseases  of  the  Male  Organs  of  Generation. 

One  or  two  preliminary  questions  arise  here :  What  is  the  value 
of  the  retained  or  ectopic  testicle?  At  what  age  ought  the  operation 
to  be  performed  ?  These  may  be  answered  together.  It  will  be 
seen  by  reference  to  the  account  given  at  page  45  {Bis.  of  Male  Org. 
of  Gen.)  of  the  condition  of  the  I'etained  or  ectopic  testicle,  if  nothing 
be  done,  that  the  following  are  certain :  (a)  That  such  a  testicle 
ultimately  becomes,  and  usually  before  adult  life  is  reached,  physio- 
logically useless ;  (h)  That,  as  some  of  the  cases  I  have  given  show, 
during  the  earl}'  years  of  life  the  testicle,  though  ill-developed,  may 
be  capable  under  more  natural  surroundings  of  becoming  a  useful 
organ ;  (c)  That  the  period  in  which  the  testicle  passes  from  a  pro- 
bably useful  into  a  useless  state  must  be  an  uncertain  one,  varying  with 
the  attacks  of  inflammation,  &c.  Most  French  surgeons  have  advised 
deferring  the  operation  until  the  age  of  about  16,  as  up  till  this  time  a 
retained  testicle  may  still  descend.  While  this  is  true,  I  should  strongly 
advocate  resoi't  to  operation  at  an  earlier  date,  a  step  which  I  have  taken 


484  OPEEATIONS  OX  THE  ABDOMEN. 

in  the  cases  given  below,  on  the  following  grounds  :  It  must  always  be 
quite  uncertain  at  what  date  structural  changes  marring  the  efficiency 
of  a  testicle  have  set  in.  These  must  depend  on  the  number  of  recurrent 
inflammatory  attacks,  and  children  are  certainly  not  exempt  from  these. 
Again,  in  cases  complicated  with  a  hernia,  the  longer  an  operation  is 
deferred  the  more  difficult  will  it  be  to  ensure  a  radical  cure.  Moreover. 
a  condition  of  this  kind,  interfering  as  it  may  do  with  activity  and 
enjoyment  of  life,  schooling,  apprenticeship,  &c.,  should  be  put  right  as 
soon  as  possible.  Finally,  if  the  testicle's  groA\'th  and  development  are 
to  be  furthered  by  the  transplantation,  and  this  is  one  great  object  of 
the  operation,  it  is  surely  more  probable  that  this  end  will  be  secured 
by  bringing  the  testicle  into  its  natural  home  before  puberty — that 
important  epoch — and  its  consequent  sexual  changes  have  set  in.  I 
should  prefer  operating  between  the  ages  of  8  and  9,  though  in  the 
case  of  the  children  of  the  poor,  where  time  is  of  great  importance,  I 
should  consider  it  cjuite  justifiable  to  operate  earlier,  especially  if  there 
has  been  any  attack  of  pain,  or  if  a  troulilesome  hernia  co-exists.  Before 
the  age  of  2  or  3  years  the  small  size  of  the  parts,  their  fragility  as  far 
as  holding  sutures  go,  and  the  difficulty  of  maintaining  asepsis  are 
contra-indications  to  operative  interference. 

The  following  account  will  be  found  to  apply  both  to  the  case  of  a 
child  and  that  of  an  adolescent. 

The  bowels  having  been  well  moved  for  a  day  or  two  before,  the  parts 
duly  cleansed  and  shaved  if  needful,  an  incision  is  made  with  the  ex- 
ternal ring  for  its  centre,  as  retention  near  this  spot  is  the  condition 
most  frequently  calling  for  operation.  This  incision  can  be  prolonged 
upwards  and  downwards  if  needful,  but  needless  weakening  of  the 
abdominal  wall  can  often  be  avoided  by  dragging  up  or  down  the  two 
angles  of  the  wound  with  retractors,  invaginating  the  scrotum,  &c. 

In  cases  of  inguinal  retention  the  testicle  is  often  subcutaneous,  and 
is  reached  after  division  of  the  external  oblique  and  intercolumnar  fascia. 

The  following  points  have  now  to  be  inquired  into : — What  is  the 
arrangement  of  the  peritonaeum  ?  Is  the  serous  sac  which  surrounds  the 
testicle  continuous  with  and  common  to  the  peritongeal  cavity  or  separated 
from  it  by  obliteration  of  the  funicular  portion  in  part?  The  sac 
around  the  testicle  or  any  prolongation  upwards  having  been  opened, 
the  above  question  is  settled.  If  the  peritoneal  process  is  open,  it 
should  be  divided  circularly  with  great  care,  so  as  to  avoid  the  cord,  a 
little  above  the  testicle.  While  the  lowest  part,  thus  left,  is  fashioned 
by  a  few  catgut  sutures  into  a  tunica  vaginalis,  the  upper  part  is  freed 
most  carefully  from  its  surroundings  as  high  as  the  internal  ring,  where 
it  is  secured  by  ligature  or  torsion,  as  the  surgeon  prefers.  If  the  peri- 
tonaeal  canal  is  found  to  be  closed  in  the  inguinal  canal  and  above  the 
testicle,  it  must  be  treated  by  the  steps  already  given  after  its  closed 
lower  end  has  been  found  and  the  process  freed.  Care  must  always  be 
taken  to  extirpate  this  process  as  far  as  possible  and  to  close  it 
thoroughly,  as  by  this  precaution  an  impoi-tant  obstruction  is  placed 
in  the  way  of  the  testicle's  remounting.  Is  a  hernia  present  ?  If  so. 
any  adhesions  to  the  testicle  being  separated,  this  is  returned  in  the 
usual  way.  But  the  presence  of  a  hernia  must  alwa3''s,  especially  -where 
there  is  any  doubt  as  to  the  condition  of  the  testicle,  incline  the  surgeon 
to  sacrifice  the  testicle  and  his  hope  of  transplantation,  and  thus  make 


ORCHIDOPEXY.  485 

sure  of  radically  curing  the  far  more  important  trouble.  Will  it  be 
possible  to  bring  the  testicle  satisfactorily  down  into  the  scrotum  ? 
How  best  will  it  be  retained  there  ?  All  adhesions  should  be  divided 
as  freely  as  possible,  the  position  of  the  cord  being  first  defined.  Where 
the  cord  seems  at  first  short,  careful,  sustained,  downward  traction  will 
oiten  be  of  much  assistance.  When  the  testicle  has  been  coaxed  or 
pushed  through  the  external  ring,  a  bed  must  be  prepared  for  it,  if 
needful,  with  the  finger  in  the  scrotum.  This  is  then  invaginated 
w^itli  the  tip  of  a  finger,  and  the  tissues  thus  presented  sutured  to 
the  testicle  with  aseptic  silk  or  chromic  gut.  The  suture  should  be 
of  silk  in  cases  where  the  operation  is  performed  at  or  after  puberty. 
In  earlier  cases  chromic  gut  will  perhaps  suffice,  though  I  prefer  well- 
carbolised  fine  silk.  The  suture  should  always  be  passed  boldly,  dipped 
well  into  the  connective  tissue  of  the  invaginated  fundus  scroti  on  the 
one  hand,  and  into  the  tunica  albuginea  of  the  testicle  or  the  tail  of  the 
epididymis  on  the  other.  I  prefer  this  method  of  invagination  to  that 
of  passing  the  suture  through  the  scrotum  from  without  inwards,  then 
next  into  the  tunica  albuginea,  then  out  of  the  scrotum  again,  and 
tying  the  ends  over  a  pad  of  gauze.  Finally,  w^hen  the  testis  is  in  sitic 
the  cord  should  be  sutured  to  the  pillars  of  the  ring  with  fine  catgut 
or  silk,  the  vas  and  the  spermatic  artery  also,  if  possible,  being  made 
out  and  inspected.  Then  this  ring  should  be  carefully  closed  with  fine 
silk,  its  pillars  being  first  defined. 

The  tendency  of  the  testicle  again  to  enter  the  vaginal  canal  is  often 
so  persistent  and  so  marked,  that  not  one  of  the  following  precautions 
should  be  omitted,  viz.: — (i)  Obliteration  of  the  funiculo-vaginal  pro- 
cess. (2)  Separation  as  far  as  possible  of  any  adhesions  which  prevent 
the  transplantation  of  the  testicle.  This  should  include  division  of  any 
bands  of  the  cremaster,  or  of  anything  which  can  keep  back  the  testicle, 
the  cord  alone  being  respected.  (3)  Suture  of  the  testicle  to  the  fundus 
scroti.  (4)  Suture  of  the  cord  to  the  pillars  of  the  external  ring,  and 
closure  of  this  opening.  (5)  In  three  cases,  to  overcome  the  tension, 
Mr.  Wood  carefully  dissected  through  the  connective  tissue  attaching 
the  testicle  to  the  globus  major,  so  far  down  as  to  enable  him  to  turn 
the  testicle  upside  down  with  the  lowest  part  of  the  epididymis 
still  attached  to  the  testis.  By  this  means  the  length  of  the  testicle 
(an  inch  and  a  half)  was  gained,  and  the  testicle  lay  without  further 
strain  topsy-turvy  in  the  scrotum,  the  cord  and  the  epididymis  being 
above  it.  This  step,  aided  by  antiseptic  details  and  proper  drainage, 
was  followed  by  perfect  success. 

After  the  testicle  has  thus  been  fixed  the  wound  is  carefully  dried, 
all  bleeding  arrested,  the  wound  closed,  and  the  dressings  applied. 

Writing  in  1 90 1,  Mr.  Jacobson  wishes  to  state  that  his  later 
experience  tends  to  show  that  this  operation  is  of  very  little  value. 
Supposing  a  scrotum  to  be  present,  everything  depends  on  whether  the 
cord  is  long  enough  to  allow  of  the  testis  resting  in  the  scrotum  without 
any  tension.  As  a  rule,  to  which  there  are  very  few  exceptions,  this  is 
not  the  case.  Out  of  seven  cases  he  has  had  only  one  permanent  and 
real  success. 

A  boy,  aet.  11,  with  iliac  reteutiou  on  the  right  side,  had  been  refused  admission  to 
the  Eoval  Xavy.  The  friends  accepted  all  risk.  The  scrotum  was  developed.  At  the 
operation  a  very  unusual  condition  was  found,  viz.,  a  loop  of  lax  constituents  of  the 


486  OPERATIONS  ON  THE  ABDOMEN. 

cord  where  they  met  at  the  internal  ring.  The  testis  was  easily  brought  down  and 
secured  in  the  scrotum,  the  layers  of  the  abdominal  wall  being  sutured  much  as  in  the 
radical  cure  of  hernia.  Two  years  later  the  boy  was  serving  on  the  North  American 
station. 

On  the  other  hand,  Mr.  Jacobson  has  known  a  testis,  fixed  in  the 
scrotum,  reascend  a  year  and  a  half  later,  during  the  pyrexia  of  an 
attack  of  influenza. 


VASECTOMY. 

The  division  or  removal  of  portions  of  the  vasa  deferentia  has  been 
largel}^  practised  during  recent  years  as  an  alternative  to  castration  for 
certain  cases  of  hypertrophy  of  the  prostate  [vide  p.  479).  The  chief 
arguments  that  have  been  advanced  in  favour  of  vasectomy  are: — (i) 
That  its  effect  on  the  prostate  is  the  same  as  that  of  castration ;  (2) 
That  the  operation  is  much  less  severe  than  castration,  and  therefore 
better  borne  by  the  type  of  patients  who  need  such  measures  ;  (3)  That 
it  meets  the  rooted  objection  to  loss  of  the  testicles  that  many  men  have, 
even  when  advanced  in  years. 

On  the  other  hand,  although  some  brilliant  successes  have  been 
recorded,  the  mortality,  as  shown  by  Wood's  figures  (loc.  supn  cit.. 
p.  480),  amounts  to  67  per  cent.,  not  veiy  much  less  than  the  present 
mortality  of  castration  for  enlarged  prostate.  Again,  the  improvement 
is  usually  not  so  great  as  after  castration,  and  it  is  not  nearly  so  certain ; 
Wood's  figures  show  that  some  improvement  took  place  in  only  6y  per 
cent,  as  against  90  per  cent,  improved  after  castration.  Finally,  there 
is  evidence  that  relapse  takes  place  in  some  of  the  cases  in  which  this 
operation  is  performed,  and  Freyer  (Lancet,  vol.  i.  1900,  p.  155),  goes  so  far 
as  to  say  that  "  In  a  very  considerable  proportion  of  the  cases  there  has 
been  no  permanent  benefit  from  this  operation."  This  might  be  ex- 
pected from  the  very  nature  of  the  operation,  which  cannot  possibly 
have  anything  like  the  same  eSect  on  the  sexual  organs  generally  that 
castration  must  have. 

This  method  of  treatment,  then,  is  to  be  recommended  onl}"  when  a 
patient,  whose  condition  is  suitable  for  treatment  b}*  castration  (vide 
p.  480),  has  refused  the  more  certain  method. 

Operation. — An  anaesthetic  having  been  given  and  the  skin  prepared, 
a  small  incision,  one-half  to  one  inch  in  length,  according  to  the  amount 
of  subcutaneous  fat  present,  is  made  over  the  spermatic  cord  opposite 
the  pubic  crest.  By  pressing  the  cord  up  into  the  wound  Avith  the 
thumb  and  index  finger  of  the  left  hand,  the  vas  can  be  quickly  found. 
and  isolated  up  by  means  of  an  aneurysm-needle  or  blunt  hook  passed 
beneath  it.  The  vas  is  now  divided,  and  its  ends  either  twisted  with 
Spencer  Wells's  forceps,  as  recommended  by  Reginald  Harrison  (Lancet. 
vol.  i.  1900,  p.  1275),  or  ligatured  with  or  without  resection  of  a  small 
portion.     Both  vasa  should  be  divided  at  the  one  operation. 


CHAPTER    XIV. 
OPERATIONS      ON     THE     ANUS     AND      RECTUM. 

FISTULA.— HEMORRHOIDS.— FISSURE.— PROLAPSUS.— 

EXCISION-       OF      THE      RECTUM.— IMPERFORATE      ANUS.— 

ATRESIA   AN"I. — IMPERFECTLY   DEVELOPED  RECTUM. 

FISTULA. 

Varieties. — As  these  have  a  very  practical  bearing  upon  the  operation 
they  must  he  alluded  to  here. 

i.  Complete,  ii.  Blind  External. — Here  an  external  opening  only 
exists,  though  in  a  considerable  number  of  cases  the  internal  opening  is 
overlooked,  iii.  Blind  Internal. — An  opening  through  the  mucous 
membrane  is  here  the  only  one.  This  is  the  rarest,  but  an  important 
variety,  as,  if  overlooked,  it  is  certain  to  be  troublesome. 

A  discoloured  dot  or  patch  of  skin  sometimes  marks  the  place  where  an 
external  opening  may  occur.  Mr.  Lund  (Hunt.  Led.,  p.  88)  relates  a 
case  in  -which  a  very  chronic  and  slowly  advancing  blind  internal  fistula 
had  excited,  by  its  extreme  end,  just  enough  inflammatory  thickening 
of  the  skin  as  to  imitate  a  keloid  growth,  for  which  it  was  at  first 
mistaken. 

Situation  of  Ojjenings. — Both  of  these  are  usually  within  an  inch, 
more  often  half  an  inch,  of  the  anus.  The  internal  one  may  be  detected 
as  a  slight  depression  or  papilla  by  the  finger,  or  by  the  speculum,  or, 
in  obscurer  cases,  by  Mr.  Lund's  method  (p.  89). 

HoiseJioe  Fistukh. — Here  an  external  opening  on  either  side  com- 
municates with  a  single  internal  one,  often  at  the  back.  Tliis  is  an 
uncommon,  but  an  important  variety,  for  if  it  is  found  necessary  to 
cut  through  the  sphincter  ani  at  both  sides,  some  loss  of  power  is  very 
likely  to  ensue.  This  risk  should  be  explained  to  the  patient,  and  the 
shallower  fistula  should  be  scraped,  while  the  deeper  is  freely  incised. 
If  it  is  necessary  to  cut  the  sphincter  on  both  sides,  the  knife  should  be 
employed  on  two  distinct  occasions,  time  being  given  for  the  first  to 
heal.* 

*  Mr.  Cripps  (_Dh.of Rictiim  and  Amts,\).  165)  shows  that  if,  in  women,  the  sphincter 
is  cut  thorough  anteriorly  where  it  decussates  with  the  sphincter  vaginae,  incontinence 
of  faeces  is  very  likely  to  take  place. 


488  OPERATIONS  ON  THE  ABDOMEN. 

Multiple  Fistulce. — This  coudition  should  always  cause  a  suspicion  of 
stricture,  or  extensive  ulceration — e.g.,  syphilitic,  &c. 

Fistula  until  Taherculosis. — Where  a  fistula  presents  an  external 
opening  with  undermined,  livid  edges,  where  the  tubera  ischii  stand 
out  prominently  from  emaciated  nates,  and  where  the  hair  of  the  part  is 
long  and  curled,  tuberculosis  is  always  to  be  suspected,  even  if  no  history 
of  cough  or  hsemoptysis  is  given. 

Question  of  Operating  on  Phthisical  PoMents. — While  each  case  must  be 
decided  by  itself,  the  following  remarks  may  be  useful :  — 

Where  the  phthisis  is  advanced,  the  cough  incessant,  the  fistula 
multiple  or  branched,  an  operation  is  out  of  the  question.  On  the 
other  hand,  where  the  physical  signs  are  little  marked,  night  sweats 
slight  or  absent,  where  the  fistula  interferes  with  the  patient  taking 
the  all-essential  exercise,  where  the  power  of  repair  is  good,  an  operation 
is  indicated. 

In  casei'  intermediate  between  the-  above,  each  one  must  be  decided 
upon  its  own  merits. 

Before  operating  the  surgeon  should  remember  that  repair  is  here 
often  sluggish,  the  mental  condition  much  depressed.  He  should  do  all 
he  can  to  improve  the  general  condition  before  and  after  the  operation. 
And  if  this  can  be  performed  in  sunny  weather,  or,  better  still,  at  the 
seaside,  so  that  the  patient  can  soon  have  fresh  air  in  the  recumbent 
position,  so  much  the  better. 

Operation. — For  a  few  days  before  the  operation  the  diet  should  be 
restricted,  and  the  bowels  emptied  by  aperients.  The  hour  of  the 
operation  should  be  so  arranged  as  to  give  time  for  the  enema,  which 
should  be  given,  to  come  away.  The  patient  being  under  an  anaesthetic, 
and  either  on  his  side  with  the  knees  well  flexed,  or  in  lithotomy  posi- 
tion, the  surgeon  introduces  lightly  a  fine  Brodie's  probe.  In  the  case 
of  a  complete  fistula,  the  internal  opening  being  hit  off  (p.  487),  the 
point  of  the  probe  is  felt  for  by  the  finger  and  hooked  out  of  the  anus. 
If,  after  careful  examination,  the  surgeon  is  satisfied  that  no  internal 
opening  exists,  he  makes  one  by  finding  the  exact  spot  at  which  the 
coats  of  the  bowel  are  most  thinned,  and  thrusting  the  point  of  the 
probe  through  here. 

In  the  case  of  a  blind  internal  fistula  the  internal  opening  must  be 
found  with  a  speculum,  and  the  probe,  curved,  passed  from  this  so  as  to 
project  beneath  the  skin.  In  every  case  the  whole  length  of  the  sinus 
between  skin  and  bowel  must  be  completely  laid  open.  When  this  has 
been  done,  very  careful  examination  is  made  for  other  sinuses  by  the 
introduction  of  the  probe,  and  b}^  pressure  with  the  finger,  which 
scjueezes  out  any  discharge,  and  feels  for  indurated  tracks.  Wherever 
these  run  they  must,  if  possible,  be  laid  open.  I  have  already  (p.  487) 
alluded,  to  the  question  of  dividing  the  sphincter  in  two  places.  If  any 
sinus  seems  to  run  dangerously  high,  hfemorrhage  may  be  avoided  by 
dividing  it  with  a  small  ecraseur,  or,  more  gradually,  by  the  elastic 
ligature.  Every  attempt,  however,  should  be  made,  w4th  the  aid  of  a 
good  light  and  forcible  dilatation  of  the  sphincter,  to  lay  open  every 
sinus  with  bistoury  or  scissors,  extra  care  being  taken,  the  higher  the 
incision  has  to  be  carried,  to  arrest  all  bleeding  with  carbolised  silk 
ligatures  or  by  leaving  on  Spencer  Wells's  forceps. 

While  the  sinuses  are  being  followed  up,  any  old  gristly  tissue  must 


H.EMOERHOIDS.  489 

be  completely  removed,  all  pyogenic  or  granulation  tissue  entirely 
scraped  out,  and  every  ill-nourished  flap  and  tag  of  undermined  skin 
cut  away. 

If  any  troublesome  piles  co-exist  they  should  be  tied  and  cut  away  at 
the  same  time  (p.  490)  or  crushed  (p.  492). 

As  a  dressing  I  prefer  a  little  twisted  salicylic  wool  dusted  with  iodo- 
form, as  I  find  this  adapts  itself  more  easily  to  the  different  wounds.  Less 
and  less  should  be  re-applied,  dailj',  as  granulations  become  established. 
After  the  first  Aveek  little  more  is  needed  than  daily  cleansing  of  the 
wound  with  a  camefs-hair  brush,  or  a  dossil  of  cotton-wool  on  a  Plaj- 
fair's  probe.  If  the  edges  of  the  wound  close  too  soon  they  should  be 
separated  with  a  probe  from  time  to  time,  or  any  redundancy  may  be 
painted  with  cocaine  and  snipped  away.* 

Finally,  no  operation  better  exemplifies  the  truth  of  Mr.  Curling's 
saying,  that  the  surgeon  should  be  his  own  dresser. 

Immediate  Union  of  Fistulse. — Mr.  Reeves  recommended  this 
treatment  some  years  ago  (Brit.  Med.  Joitrn.,  vol.  i.  1887,  p.  917).  It 
certainly  has  the  advantage  of  often  shortening  the  treatment  greatly, t 
and  preventing  loss  of  sphincter  power,  but  at  the  risk  of  two  dangers  : 
(i)  Sepsis.  (2)  The  part  within  the  bowel  is  sometimes  difiicult  to 
suture  satisfactorih^  and  may  persist  as  a  sinus  later.  The  method  may 
be  tried  in  simple  cases  which  do  not  extend  far  into  the  bowel. 

Operation. — The  anus  having  been  well  dilated,  the  fistula  is  laid 
open,  thoroughly  scraped  out,  any  skin  or  mucous  membrane  which  is 
unhealth}^  or  which  will  get  between  the  edges  of  the  wound  must  be 
snipped  away,  the  bleeding  stopped,  the  wound  well  irrigated  with  lot. 
hydr.  perch,  (i  in  4000)  and  well  dried  out.  It  is  then  united  in  its 
whole  extent  by  sutures  of  salmon-gut  or  sterilised  silk.  These  are  left 
in  for  a  week  or  ten  days.  During  this  time  the  boA^els,  which  have 
been  previously  (daily)  thoroughly  emptied  and  cleansed  with  naphthol, 
must  not  act.  A  glycerine  or  oil  enema  must  prevent  any  passage  of 
scybala  and  straining  at  the  time  of  the  first  relief. 


HEMORRHOIDS. 
Indications. 

1.  Continuance  of  ha?moiTliage  or  discharge,  and  persistent  liability 
to  descent  of  piles  in  spite  of  judicious  treatment. 

2.  Absence  of  albuminuria,  diabetes,  and  hepatic  (probably,  cardiac) 
disease. 

3.  Amenability  on  the  part  of  the  patient. 

In  Mr.  Crippss  words  (loc.  suj^ra  cit.,  p.  99):  "'  The  smallness  of  the 
risk  should  not  lull  the  surgeon  into  a  sense  of  absolute  securit}*,  and 
he  should  spare  no  effort  in  ascertaining  the  general  constitutional  con- 
dition of  his  patients The  amount  of  risk,  slight  as  it  is,  should 

be  clearly  laid  before  the  patient  or  his  friends.     If  a  man  is  to  have 
some  grave  operation  performed,  such  as  the  removal  of  a  cancer  or  the 


*  Another  excellent  dressing,  later  on,  is  tr.  bcnz.  co.  or  dilute  nitric  acid  lotion 
10  minims  to  i  oz.     The  latter  needs  changing  every  four  hours. 

f  It  is  right  to  add  that  the  tediousncss  of  the  after-treatment  is  often  due  to  the 
patient  refusing  to  lie  up,  or  to  inefficient  attention  on  the  part  of  the  surgeon  himself. 


490 


OPERATIONS  ON  THE  ABDOMEN. 


becomes,  so  tragic 


from 


Fig.  192 


amputation  of  a  limb,  both  he  and  his  friends  are  well  aware  of  the 
risk  involved,  and  are  accordingly  jDrepared.  It  is,  therefore,  in  the 
smaller  operations,  regarded  by  the  surgeon  and  public  as  free  from 
danger,  that  a  fatality,  when  it  does  occur, 
being  unexpected." 

Operations. 

Ligature. — Cautery. — Crushing. — Acid. — Whitehead's  Operation. 
— Thelwell  Thomas's  Operation. 

i.  Ligatiire. — I  have  placed  this  first,  from  a  strong  belief  that,  if 
pro])erly  used,  it  is,  on  the  Avhole,  the  best  method  and  the  one  most 
generally  applicable.  Here,  as  elsewhere,  that  surgeon  will  have  the 
best  results  who  has  thoroughly  familiarised  himself  with  the  details  of 
one  operation.  The  following  appears  to  me  to  be  a  fairway  of  putting 
the  merits  of  ligature  and  the  other  operations  : 

i._  In  my  opinion  the  ligature  is  more  generally  suited  to  all  cases. 
Again,  it  can   be  more  easily  applied  to   piles  high  up  than  can  the 

cautery.  2.  No  special  instruments 
are  needed.  3.  A  ligature  applied 
is  done  once  for  all ;  the  cautery 
may  have  to  be  reapplied  more  than 
once  if  bleeding  follows  when  the 
II  ''  -^\».  ^'^^^^  """"m^         clamp  is   unscrewed.      4.  The  risk 

if'  "^^^^  '/^         of  bleeding  is  less,  and  hence  this 

method  is  especially  advantageous 
in  anaemic  patients,  and  in  those 
for  whom  it  might  be  difficult  to 
immediately  obtain  surgical  aid 
fAllingham).  5.  The  ligature  is 
free  from  the  objections  to  the 
cautery  in  private  practice — viz., 
the  smell,  and.  unless  a  Paquelin's 
cautery  is  at  hand,  the  cumbersome  appai*atus  otherwise  rarely  used. 
^  Operation. — The  preparatory  treatment  is  that  given  at  p.  488. 
The  patient  being  on  his  left  "side,  or  in  the  lithotomy  position,  the 
anus  should  always  be  dilated.  This  may  be  done  by  introducing,  and 
then  separating  laterally,  the  two  thumbs  (Fig.  192),  "the  pressure  being 
steadily  maintained  so  as  not  to  rupture  the  mucous  membrane ;  after 
a  few  minutes  a  sensation  of  yielding  rather  than  of  tearing  is  per- 
ceived. Another  method  is  to  introduce  a  large  bi-  or  multi-valve 
vaginal  speculum,  and  to  withdraw  this  expanded.*  When  the 
sphincters  are  thoroughly  dilated  the  piles  which  lie  lowest  according 
to  the  patient's  position f  are  drawn  down  with  a  vulsellum  or 
tenaculum-forceps,  and  the  surgeon,  with  blunt-pointed  scissors,  curved 
on  the  ilat,  cuts  a  groove  around  the  lower  two-thirds  of  the  pile,  which 
is  thus  separated  for  this  distance  from  the  sub-mucous  and  muscular 
coats.     In  the  lower  piles  this  groove  should  commence  in  the  sulcus. 


Forcible  dilatation  of  the  sphincters. 
(Esmarch  and  Kowalzig). 


*  Eversion  of  the  rectal  mucous  membrane  by  a  finger  in  the  vagina  will  often  be 
most  helpful  in  bringing  piles  within  reach. 

t  This  prevents  the  other  haemorrhoids  being  obscured  with  blood.  Mr.  Allingham 
advises  that  the  smallest  piles  should  be  taken  first,  as  there  is  a  danger  of  these  being 
overlooked  and  thus  leading  to  a  recurrence  of  the  disorder. 


ILEMOERHOIDS.  49 1 

which  marks  the  junction  of  skin  and  mucous  membrane  close  to  the 
anus.  The  object  of  this  groove  is  twofold.  It  forms  a  bed  in  which 
the  ligature  can  be  sunk  tightly,  and,  above  all,  it  leaves  a  very  small 
pedicle  of  tissues  to  be  strangled.  The  groove,  moreover,  can  be  cut 
without  risk  of  hgemorrhage,  as,  however  large  the  pile,  its  vessels  enter 
it  from  above,  running  into  its  upper  part  just  beneath  the  mucous 
membrane.  The  surgeon  then  ties  round  each  pile,  which  is  now  still 
further  dragged  down,  a  ligature  of  well  carbolised  silk,  the  strength  of 
AA-hich  he  has  previously  tested.  Sinking  this  into  the  groove,  he 
tightens  it  up  so  as  to  embed  his  ligatures  iirmly.  without  cutting 
through  the  pedicle.  About  two-thirds  of  the  pile  are  then  cut  away, 
enough  being  always  left  to  ensure  a  safe  hold  for  the  ligature.  In 
Allingham's  Diseases  of  the  Rectum,  p.  146,  the  following  most  important 
practical  point  is  insisted  on.  When  the  piles  are  separated  from  the 
bowel  prej^aratory  to  applying  the  ligature,  it  is  essential  that  the  base 
to  be  ligatured  should  be  as  narrow  as  is  consistent  with  safe  securing 
of  its  blood-supply.  For  if  many  piles  have  to  be  tied,  and  their  bases 
are  left  large  and  broad,  when  tied  up  they  draw  the  mucous  membrane 
together,  and  cause  great  narrowing  of  the  rectum.  In  such  a  case  it  is 
almost  impossible  to  introduce  the  finger,  without  force,  beyond  the 
parts  tied.  In  other  words,  islets  of  untied  mucous  membrane,  as  wide 
as  possible,  should  always  be  left  between  the  tied  piles.  This  will 
secure  less  pain,  easier  action  of  the  bowels,  and  less  risk  of  contraction. 
After  every  internal  pile  has  been  carefully  treated  in  this  way,  the 
external  ones  are  partly  clipped  away,  care  being  taken  not  to  encroach 
upon  the  junction  of  skin  and  mucous  membrane,  and  not  to  remove 
subcutaneous  tissue  for  fear  of  subsequent  contraction.  If  any  bleeding- 
points  still  persist,  they  should  now  be  tied.  The  ligatures  are  all  cut 
short,  and  lastly  the  stumps  of  the  piles,  after  thorough  irrigation  with 
lot.  hydr.  perch.  (1-4000)  and  rubbing  in  of  iodoform  powder,  are 
returned.  A  morphia  sup2:)ository  is  then  introduced,  strips  of  iodoform 
gauze  wrung  out  of  carbolic-acid  lotion  applied,  and  firm  pressure  made 
^^ith  a  T-bandage  and  the  aid  of  a  pad  of  salicylic  wool,  carbolised 
tow,  or  "tarred  cotton." 

ii.  Clamp  and  Cautery. — This  method  has  been  perfected  by  Mr.  H. 
Smith.*  The  preparatory  treatment  and  position  of  the  patient  are 
those  already  given.  The  piles  having  been  sufficiently  protruded,  and 
the  anus  forcibly  dilated,  they  are  drawn  well  down,  one  by  one,  with 
vulsellum  forceps,  and  enclosed  within  the  blades  of  the  clamp,  which  is 
screwed  tightly  up.  With  scissors  curved  on  the  flat  the  ]nle  is  then  so 
cut  away  as  to  leave  a  sufficient  stump.  This  is  then  carefully  and 
thoroughly  seared  down  with  a  Paquelin's  cautery,  carefully  kept  at 
a  dull  red  heat.  If  the  iron  sticks  at  any  moment,  owing  to  its  cooling- 
down,  it  should  not  be  pulled  away,  but  loosened  by  heating  it  a  little. 
The  clamp-screw  is  then  slightly  relaxed,  and  if  any  bleeding  takes 
place  it  is  at  once  tightened  up.  and  the  cautery  reapplied.  Even*  care 
must  be  taken  to  burn  down  the  stump  thoroughly  at  the  first  attempt, 
for  if  this  fail,  and  oozing  take  place,  it  is  not  easy  to  stop  the  bleeding, 

*  Mr.  H.  Smith  CSysf.  of  Surg.,  vol.  ii.  p.  840)  had  almost  entirely  discarded  the  use 
of  scissors,  removing  the  clamped  piles  with  heated  cauteries  instead.  Three  of  these 
iire  figured. 


492  OPERATIONS  OX  THE  ABDOMEN. 

from  the  tendency  of  tlie  stump  to  slip  through  the  slackened  clamp. 
The  piles  having  been  successively  dealt  with  in  this  way,  the  stumps 
are  smeared  with  iodoform  ointment  and  pushed  well  up  ^^•ith  a  finger 
coated  with  the  same. 

This  method  is  thought  by  some  to  secure  more  rapid  healing  with 
less  pain  than  the  ligature.  This,  however  true  of  the  old  methods,  does 
not  hold  good  when  the  piles  are  freely  detached  and  the  ligature  tied 
with  the  precautions  already  given.  The  clamp  is  less  easily  manipu- 
lated in  the  rectum,  it  is  a  special  instrument  not  always  at  hand,  and 
the  smell  entailed  by  the  cautery  is  most  unpleasant.  The  surgeon  who 
uses  it  must  be  extremely  careful  to  keep  his  seared  surfaces  as  small  as 
possible,  and  by  no  means  to  entrench  upon  the  skin.  It  is  well  known 
ho^^■  slowly,  how  painfully,  and  ^^"ith  what  a  tendency  to  contraction 
burns  heal. 

iii.  Crushing. — This  method  was  prominently  Ijrought  forward  by 
Mr.  Pollock  (Lancet,  vol.  ii.  i88o,  p.  i  et  ijassim)  as  less  painful  than 
the  ligature,  and  as  leaving  a  mere  thin  and  superficial  fringe  of 
dead  tissue,  instead  of  the  slough  of  the  clamp  and  cautery.  The  anus 
being  fully  dilated,  each  pile  is  drawn  down  A\'ith  a  vulsellum,  and 
firmly  crushed  for  a  period  varying  from  one  to  three  minutes.  The 
projecting  part  of  the  pile  should  then  be  cut  away.  The  best 
instrument  is  Mr.  H.  W.  Allingham's  "  screw-crusher."  This  has 
enormous  power,  and  possesses  the  advantage  that  it  may  be  introduced 
into  the  bowel.  Skin  should  not  be  crushed,  an  incision  being  always 
made,  when  needful,  at  the  junction  of  skin  and  mucous  membrane. 
The  upper  part  of  the  instrument  should  rest  within  the  rectum,  so  as 
not  to  drag  on  the  mucous  membrane.  Mr.  Allingham  (Bis.  of  Bectum, 
p.  133)  has  found  that  pain  after  this  method  is  rather  less  than  after 
the  ligature,  and  that  recovery  is  somewhat  more  rapid.  CEdema  of  the 
parts  outside  may  be  very  marked  ;  '•  contraction  so  as  to  require  dilata- 
tion by  bougie  or  finger  occurred  about  as  frequently  as  after  any  other 
method  of  operation  upon  piles,  but  far  less  than  after  the  cure  by  the 
actual  cautery."  Haemorrhage  is  extremely  rare  after  careful  tise  of 
the  screw-crusher.  If  it  occurs,  it  is  best  arrested  by  leaving  on 
Spencer  Wells's  forceps.  Mr.  Allingham  gives  the  following  advice 
as  to  suitable  and  unsuitable  cases  :  ''It  may  be  used  when  the  piles 
are  small  and  not  nanierous,  say  three  in  number.  It  may  be  applied 
to  remove  a  pile  or  two  when  operating  for  fistula.  Partial  prolapse 
of  the  mucous  membrane  falls  within  the  same  category.  I  should 
not  advise  its  use  in  cases  of  very  large  vascular  piles,  in  which,  from 
excessive  htemorrhage,  the  blood  is  poor  and  non-coagulable.  In  cases 
of  antemia  as  a  result  of  haemorrhage,  m  which  recurrent  or  secondary 
hemorrhage  would  probably  cost  the  patient  his  life,  this  method  is 
decidedly  dangerous.  It  should  not  be  used  to  remove  inflamed  piles. 
It  is  not  wise  to  crush  piles  when  the  patient  is  at  a  distance  from 
skilled  assistance,  for  fear  of  haemorrhage  coming  on." 

iv.  Acid. — This  method,  formerly  much  over-rated,  should  be  reserved 
for  that  rai'e  variety  of  pile,  sessile,  perinseal,  usually,  in  position,  and 
with  a  florid,  granular  surface.  Vaseline  having  been  applied  abound, 
the  surface  of  the  pile  is  dried,  and  carefully  rubbed  over  with  fresh, 
strong  nitric  acid,  or  acid  mercury  nitrate,  this  being  thoroughly  applied 
with  a  glass  rod  or  pointed  bit  of  wood.    The  acid  should  be  rubbed  in  and 


ILEMOEPJIOIDS.  493 

in.  the  pile  beino-  kept  dry  and  the  acid  not  allowed  to  run.  Ev^ery  atom 
of  the  florid  surface  must  be  converted  into  a  brownish,  sha^ory  slough. 

V.  Whitehead's  *  Operation  of  Excision  of  the  whole  "  Pile- 
bearing "  Area. — This  extensive  operation  is  intended  to  bring  about  a 
radical  cure,  its  object  being  not  only  to  remove  any  existing  piles,  but 
also  all  the  mucous  membrane  in  the  lowest  part  of  the  rectum,  which  is 
the  seat  of  piles,  owing  to  the  tendencj'  of  its  veins  to  become  dilated. 
Though  Mr.  Whitehead  has  performed  this  operation  in  three  hundred 
cases  without  a  fatal  result  or  any  drawback,  I  cannot  but  consider  it 
needlessly  extensive  and  severe,  especially  in  patients  of  middle  life, 
and  in  a  part  which  cannot  always  be  kept  sweet,  even  with  the  aid 
of  iodoform.  The  operation  bj"  ligature,  or  by  clamp  and  cautery,  care- 
fully performed,  gives  most  excellent  results,  and  in  answer  to  Mr.  White- 
head's argument,  that  as  long  as  this  diseased  area  is  left  to  reproduce 
piles  over  and  over  again,  no  permanent  cure  can  be  expected,  I  may 
say  that  I  have  always  found  that,  after  one  of  the  above  operations  has 
been  properly  carried  out,  the  patient  can  easily  prevent  any  recurrence 
by  attention  to  common-sense  details  in  daily  life.  Finally,  I  knoAv  of 
one  case,  in  a  young,  healthy  patient,  fatal  from  blood-poisoning. 

The  following  criticism  (Allingham,  Dis.  of  Bectum,  p.  139)  appears 
to  me  soundly  based :  "  Mr.  Whitehead  terms  his  operation  simple. 
Simple  it  may  be,  but  difficult  to  perform,  for  with  the  anus  rugose 
and  elastic  as  it  is,  even  after  dilatation  of  the  sphincters,  it  is  not 
at  all  easy  to  separate  the  mucous  membrane  from  the  skin.  The 
time  required  for  the  operation  is  an  objection ;  this  process  takes 
on  an  average  at  least  thirty  minutes,  where  a  skilled  surgeon  can 
operate  with  the  ligature  in  less  than  five  minutes.  The  haemorrhage 
by  this  method  far  exceeds  the  amount  lost  when  the  ligature  is  used, 
and  this  is  of  great  importance  in   those  patients  who   have  already 

lost  much  blood  from  their  j)iles Two  or  three  days  after  the 

operation  the  parts  not  infrequently  become  swollen,  and  the  mucous 
membrane  then  tears  through  the  ligatures  and  retracts  away  from 
the  skin.  This  leaves  a  large  granulating  surface  which  may  occupy 
the  entire  circumference  of  the  bowel,  and  cause  troublesome  contraction. 

Operation. — The  sphincters  having  been  thoroughly  dilated,  and  the 
htemorrhoidal  area  of  mucous  membrane  made  to  prolapse,  the  line  of 
junction  of  skin  and  mucous  membranef  is  looked  for,  and  the  latter 
divided  along  it  all  round  the  anus  with  blunt-pointed  scissors.  The 
cut  mucous  membrane  is  then  dissected  uj).  with  forceps  and  scissors, 
from  off  the  external  and  (in  part)  the  internal  sphincter,  till  the  whole 
of  the  pile-producing  area  of  mucous  membrane  can  be  pulled  down 
and  drawn  outside  the  anus.  It  is  then  cut  away,  bit  bv  bit,:f  trans- 
versely at  its  still  attached  upper  border,  each  portion  when  divided 
being  at  once  attached  to  the  cut  skin  with  carbolised  silk  sutures. 
In  this  ^\'ay  the  diseased  area  is  removed  as  a  complete  ring  of  mucous 
membrane.  Each  bleeding-point  is  secured  by  torsion  or  forcipressure. 
Iodoform  is  dusted  over  the  wound.  The  sutures  are  allowed  to  come 
awav  of  themselves. 


*  Srit.  Med.  Journ...  Feb.  26,  1887. 

f  The  "  white  line  "  of  Mr.  Hilton  {Rest  and  Pain,  p.  289,  Figs.  51  and  52). 

X  So  as  to  diminish  the  haemorrhage,  which  would  otherwise  be  free  at  this  stage. 


494  OPERATIONS  ON  THE  ABDOMEN. 

vi.  Thelwell  Thomas's  Operation  {Brit.  Med.  Journ.,'NoY.  26,  1898). 
— Mr.  Thelwell  Thomas  has  devised  the  following  operation.  The  great 
advantages  that  he  claims  for  it  are — (i)  that  primary  imion  is 
obtained,  and  so  convalescence  is  more  rapid  ;  (2)  that  reactionary 
and  secondary  haemorrhage  are  prevented. 

Operation. — The  sphincter  having  been  stretched,  "a  large  pile  is 
seized  by  artery  forceps,  and  its  base  clamped,  the  clamp  being  always 
put  on  in  the  long  axis  of  the  bowel.  I  have  most  frecpiently  used 
Smith's  clamp,  but  a  dressing  forceps  with  a  catch  will  do  quite 
as  well.*  The  bulk  of  the  pile  is  cut  away,  leaving  a  small  stump 
standing  off  the  clamp.  The  treatment  of  this  is  the  essential  feature 
of  the  operation.  A  piece  of  catgut,  not  too  fine,  about  a  foot  in 
length,  with  a  domestic  needle  at  each  end,  is  used  for  a  suture. 
Commencing  at  the  top  end  of  the  stump  one  needle  is  passed  through, 
and  the  catgut  follows  until  there  is  one  half  the  length  of  the  suture 
on  each  side,  with  its  own  needle  attached.  A  reef  knot  is  tied  on 
the  stump,  and  the  needle,  which  is  on  the  right  side,  is  brought 
over  to  the  left  and  passed  throiigh  the  stump  lower  down  and  back 
again  to  the  right.  The  needle  which  is  on  the  left  is  taken  over  to 
the  right  and  passed  through  the  stump  back  to  the  left  immediately 
adjoining  the  previous  one.  A  reef  knot  is  again  made,  and  so  on 
to  the  end  of  the  stump,  making  five  or  six  crossings  to  the  inch. 
This  method  of  suture  brings  the  cut  edges  of  the  mucous  mem- 
brane tightly  together,  and  its  advantage  over  a  simple  continuous 
suture  is  apparent,  each  cross  and  knot  making  each  segment  inde- 
pendent of  the  next.  The  clamp  is  slackened,  and  occasionally,  though 
rarely,  it  may  be  necessary  to  tie  a  small  vessel  at  the  top  end  of  the 
stump,  particularly  if  a  cross-acting  clamp  is  used.  All  the  internal 
piles  are  thus  treated." 

Mr.  Thomas  has  performed  forty-five  operations  in  this  way  with 
extremely  satisfactory-  results.  The  bowels  were  opened  on  the  fifth 
day,  and  full  diet  w^as  given  on  the  eighth  day.  No  pain  was  com- 
plained of,  and  none  had  any  haemorrhage  or  inflammation.  The 
average  stay  in  hospital  of  the  fortj^-five  cases  was  8'8  days.f 

Causes  of  Tailuxe  and  Trouble  after  Operations  for  Haemorrhoids: 

I .  Hgemorrhage. — This  will  be  extremely  rare  if  the  ligature  method 
be  carefully  employed.  The  conditions  under  which  this  complication 
may  occur  are  cases  of  long-standing  piles  or  prolapsus  in  weakly 
subjects,  cases  where  the  tissues  are  very  friable,  where  the  patient 
insists  on  getting  out  of  bed  to  pass  water,  or  where  he  strains  very 
much  at  the  first  action  of  the  bowels.  If  the  surgeon  be  called  upon 
to  meet  it,  the  best  means  is  to  apply  Spencer  Wells's  forceps,  and  to 
leave  these  in  situ;  in  a  severer  case,  or  where  the  above  are  not 
available,  Mr.  Allingham"s  plan  of  plugging  should  be  used  (Dis.  of 
the  Bedum,  p.  67).  Through  a  conical  sponge  a  silk  ligature  is 
threaded  from  apex  to  base.  The  sponge,  well  dusted  with  iodoform 
and  steel  sulphate,  is  pushed  four  or  five  inches  into  the  bowel,  and 
the  whole  of  the  space  below  it  is  plugged  with  aseptic  gauze.     The 

*  Later  Mr.  Thomas  says  that  he  has  found  Doyen's  broad  ligament  clamp  (small 
size)  superior  to  all  others. 

•f  This  is  certainly  too  short.    The  patient  should  be  kept  recumbent  for  three  weeks. 


FISSURE— ULCER.  495 

sponge  is  now  pulled  d^ovn  by  the  two  ends  of  the  ligature  while 
the  gauze  is  pushed  iqi.  The  plug  should  be  left  in  as  long  as  possible, 
the  patient  being  kept  iinder  the  influence  of  laudanum.  It  is  well 
to  pass  a  large  catheter  through  the  sponge  before  this  is  inserted, 
to  allow  of  escape  of  flatus.  2.  Tedious  ulceration. — This  is  usually 
due  to  the  patients  getting  up  too  soon.  They  should  remain  in  bed 
a  week  or  ten  days,  and  then  be  content  to  pass  another  ten  or  fourteen 
days  upon  the  sofa.  3.  Septic  troubles.  4.  Contraction. — This  is  usually 
stated  to  be  only  likely  to  occur  when,  in  cutting  away  piles,  especially 
external  ones,  the  junction  of  skin  and  mucous  membrane  is  trenched 
upon.  But  the  fact  is  that  where  many  piles  have  had  to  be  removed, 
where  islands  of  mucous  membrane  (p.  491)  have  not  been  left  between 
them,  the  ulcerated  surfaces  thus  tending  to  coalesce,  contraction  of  the 
surface  as  it  cicatrises  is  very  likely  indeed  to  lead  to  some  narro"v\'ing 
of  the  lumen  of  the  gut.  This  must  always  be  prevented  by  the  early 
passage  of  the  finger  of  the  surgeon  in  charge,  this  being  repeated 
daily  if  any  tendency  to  contraction  is  found.  Where  a  stricture, 
generally  about  one  inch  and  a  half  from  the  anus,  has  been  allowed 
to  form,  the  patient's  condition  is  a  most  vexatious  one,  though  it  will 
always  yield  to  the  use  of  bougies,  aided,  if  need  be,  by  nicking  of  the 
contraction.  5.  Abscess.  6.  Fistula.  7.  Bubo.  8.  Pelvic  suppura- 
tion. These  four  are  given  by  Mr.  Allingham  (loc.  supra  cit.,  p.  163) 
as  sequelae  in  unhealthy  patients,  especially  if  the  healing  has  been 
accompanied  by  prolonged  suppuration.  The  antiseptics  of  the  present 
day  should  prevent  this. 


riSSURE.*— ULCER. 

The  operative  treatment  of  these  is  so  simple  and  so  eminently 
successful,  that  it  should  be  resorted  to  early. 

Operation  by  Incision. — The  preparatory  treatment  and  the  position 
of  the  patient  are  the  same  as  those  already  given.  The  division  of  the 
ulcer  may  be  performed  in  one  or  two  ways — (a)  From  without ;  (h>)  from 
within  the  rectum. 

(a)  From  irifhout.  —  Here  the  ulcer,  being  fully  exposed  with  a 
speculum — and  the  one  which  bears  Mr.  Hilton's  name,  with  a  movable 
valve,  will  be  found  the  best — a  small  sharp-pointed  bistoury  is  inserted 
a  little  beneath  the  base  of  the  ulcer,  and  its  point  made  to  protrude  in 
the  bowel  above  it ;  the  parts  are  then  divided  from  without  inwards 
through  the  centre  of  the  ulcer. 

(h)  From  ivitJiin. — Here,  the  ulcer  being  also  exposed,  either  by 
stretching  the  parts  with  two  fingers  or  with  a  speculum,  a  straight 
blunt-pointed  bistoury  is  drawn  across  the  whole  of  the  sore,  through  its 
centre,  going  deep  enough  to  divide  about  a  third  of  the  fibres  of  the 
external  sphincter.  Mr.  Curling  (Lis.  of  the  Bectum,  p.  I2j  has  drawn 
attention  to  an  important  point  here,  and  that  is,  that  the  fibres  of  the 
muscle  at  the  extremity  of  the  ulcer  near  the  verge  of  the  anus  should 
be  divided  rather  more  freely  than  those  above,  so  as  to  avoid  any  ridge 
or  shelf  on  which  the  faeces  would  lodge. 


*  TMs  condition,  often  called  a  fissure,  nearly  always  amoants  to  an  ulcer  when 
it  is  carefully  examined  and  the  parts  unfolded. 


496  OPERATIONS  ON  THE  ABDOMEN. 

There  is  usually  no  hgemorrhage  to  speak  of,  and  the  whole  operation 
is  so  simple  that  it  may  be  performed  after  an  injection  of  cocaine, 
or  with  nitrous  oxide  gas,  unless  anything  else — e.g.,  attention  to  piles 
— is  required.  I  prefer,  however,  to  operate  with  ether  or  the  A.C.E. 
mixture. 

Of  the  two  methods,  I  generally  make  use  of  the  first,  following 
Mr.  Hilton.  I  consider  it  the  more  certain,  and  have  never  known  of 
anything  like  incontinence  in  the  nine  cases  in  which  I  have  used  it. 
The  second  is  rather  the  slighter  operation,  and  also  gives  good  results. 

The  position  of  these  usually  club-shaped  ulcei's  is  posterior.  If  one 
is  met  with  anteriorly  in  a  woman,  it  would  be  wiser  to  try  the  applica- 
tion of  acids,  or  the  actual  cautery.     See  footnote,  p.  487. 

The  surgeon  must  be  careful,  when  examining  into  the  amount 
of  repair  a  week  or  two  later,  not  to  do  any  damage  if  a  speculum 
is  employed. 

Operation  by  Dilatation  of  the  Sphincter. — This  is  not  only  rough 
but  uncertain,  and  should  not  be  employed. 


PROLAPSUS. 

Indications. — Failui'e  of  previous  treatments.  Large  size  and  long- 
duration  of  the  prolapsus.  Altered  condition  of  the  mucous  membrane 
— viz.,  thickening  or  ulcers,  the  latter  giving  rise  to  haemorrhage. 
Incontinence  of  faeces,  especially  when  fluid,  or  of  flatus. 

Operations. 

Acid. — Cautery. — Excision. 

1 .  Acid. — Of  these  I  prefer  the  acid  nitrate  of  mercury.  This  method 
is  especially  applicable  to  the  obstinate  cases  of  prolapsus  in  children, 
where  the  bowel  is  constantly  down.  Though,  if  the  application  is  made 
properly,  only  a  sensation  of  burning  is  complained  of,  an  anaesthetic 
should  always  be  given.  The  patient  being  in  the  lithotomy  position, 
or  on  one  side,  the  prolapsus  is  carefully  dried  of  all  mucus,  and  the 
surgeon  rubs  in  the  acid  with  the  aid  of  a  glass  rod  or  pointed  pieces  of 
wood,  the  adjacent  skin  being  protected  with  vaseline. 

Care  must  be  taken  not  to  rub  in  the  acid  too  long  or  too  vigorously, 
for  if  the  inflammatory  process  set  up  affects  deeply  the  sub-mucous 
tissue,  a  most  troublesome  stricture  may  readily  result. 

It  is  well  to  warn  the  patients  that  a  second  application  may  be 
required  in  severe  cases. 

The  after-treatment  is  that  given  below. 

2.  Cautery. — In  severer  cases,  or  where  the  acid  has  failed,  the 
following  will  be  found  efficient.  The  position  of  the  patient  is  as  for 
pile  operations,  but  it  is  best  to  apply  the  cautery  to  the  bowel  in  situ, 
though  this  may  be  used  when  the  bowel  is  prolapsed. 

Thus,  the  patient  being  in  lithotomy  position,  and  a  duckbill-speculum 
introduced  and  held  in  contact  with  the  anterior  wall  of  the  rectum,  the 
blade  of  a  thermo-cautery  is  drawn  edgeways  along  the  lower  three  or 
four  inches  of  the  opposite  surface  of  the  gut.  The  speculum  being 
shifted,  the  anterior  and  lateral  aspects  are  similarly  treated  in  severe 
cases. 

Care  must  be  taken  not  to   go  throiujh  the  mucous  membrane,  or 


PIKJLAPSUS.  497 

septic  mischief  and  sloughing  may  be    set    up  in  the  cellular  tissue 
beneath. 

3.  Excision. — In  severe  cases,  in  adults,  when  other  methods  have 
failed,  this  metliod  should  be  resorted  to,  but  even  with  the  improvements 
of  the  present  day  there  must  always  be  a  difficulty  in  keeping  wounds 
here  aseptic.  Either  portions  of  mucous  membrane  only,  or,  in  very 
severe  and  intractable  cases,  the  whole  prolaj^se,  may  be  removed. 

i.  Excision  of  mucous  membrane. 

The  patient  being  in  lithotomy  position,  the  prolapsus  reduced,  and 
the  parts  exposed  by  a  duckbill-s])eculum,  two  or  more  elliptical  pieces 
of  mucous  membrane  are  removed  by  pinching  them  up  with  vulsellum- 
forceps  and  cutting  them  away  with  a  very  sharp  scalpel  or  scissors. 
Any  bleeding  vessels  are  then  tied  with  chromic  gut,  and  the  edges 
of  the  wound  united  by  horsehair  or  fishing-gut  sutures.  Iodoform  is 
then  carefully  dusted  on,  and  the  parts  smeared  with  an  ointment  of 
the  same. 

The  insertion  of  sutures  has  the  advantage  of  preventing  liaBmorrhage, 
and  hastening  the  cure.  If  the  sutures  have  to  be  removed,  especial 
care  will  be  needed  not  to  break  down  the  union  with  the  speculum. 
The  wounds  must  be  irrigated  frequently  with  a  solution  of  hydi-.  perch 
(i  in  4000).  and  a  small  Higginson's  syringe. 

ii.  Complete  removal  of  the  prolapse. 

Although  a  more  certain  cure,  this  method  is  much  more  severe  than 
those  already  described,  and  owing  to  the  risk  of  the  operation,  should 
be  reserved  for  cases  in  which  other  methods  of  treatment  have  failed, 
the  prolapse  has  become  irreducible,  or  when  gangi-ene  threatens. 

The  operation  essentially  consists  of  amputation  of  the  prolapsed 
bowel,  with  suture  of  the  divided  edges  at  the  margin  of  the  anus. 

It  must  be  remembered,  however,  that  a  pouch  of  peritonaeum  may  be 
present  in  front  between  the  layers  of  the  prolapsed  bowel,  and  that,  in 
certain  cases,  a  herniated  loop  of  intestine  may  lie  within  this  pouch. 
Owing  to  the  vascularity  of  the  parts  considerable  haemorrhage  may 
occur,  and,  with  a  view  to  controlling  this,  several  operators  have 
advised  constriction  of  the  base  of  the  prolapse,  either  by  means  of 
specially  devised  clamps,  or  by  an  elastic  ligature,  applied  above  trans- 
fixing pins,  before  commencing  its  removal.  The  objection  to  this  is, 
however,  the  possibility  of  damage  to  a  knuckle  of  small  intestine  lying 
in  a  prolapsed  peritonaeal  pouch.  Moreover,  the  haemorrhage  may  be 
satisfactorily  dealt  with  by  dividing  only  small  portions  of  tissue  at  a 
time  and  applying  catgut  ligatures  to  the  vessels  in  each  portion  as  they 
are  divided. 

The  details  of  the  operation  have  been  varied  by  many  surgeons,  one 
of  the  best  methods  being  undoubtedly  that  of  Mickulicz,  which  is 
described  as  follows  by  Cumston,  of  Boston  (Ann.  of  Surg.,  March,  1900). 
in  a  paper  containing  much  valuable  information  : 

"  Mickulicz  first  cuts  through  the  outer  intestinal  tube  in  its  anterior 
circumference  by  cutting  the  tissues,  layer  after  layer,  catching  up  each 
bleeding  vessel  as  it  appears,  and  ligating  it  with  fine  catgut.  As  soon 
as  the  peritonajal  pouch  has  been  opened,  its  interior  is  examined  for 
the  presence  of  small  intestine.  The  peritonaeal  cavity  is  then  closed  by 
a  running  suture.  The  anterior  aspect  of  the  internal  intestinal  tube  is 
cut  through,  little  by  little,  until  it  is  opened,  and  then  both  intestinal 
VOL.  II.  32 


498  OPERATIONS  OX  THE  ABD03IEN. 

tubes  are  united  by  deep  silk  sutures  along  the  entire  line  of  the 
incision. 

"The  posterior  circumference  of  the  prolapse  is  treated  in  absolutely 
the  same  way,  both  intestinal  ends  being  united  bj^  means  of  silk  sutures, 
and  thus  the  resection  is  completed." 

After-treatment. — After  any  operation  for  prolapsus,  the  patient 
must  rest  for  three  weeks  on  the  sofa  to  allow  of  firm  consolidation  and 
cicatrisation  taking  place.  Light  diet  alone  should  be  allowed  at  first, 
and  the  bowels  should,  at  first,  be  allowed  to  act  only  every  three  days, 
and,  if  possible,  while  the  patient  is  on  his  side. 


EXCISION    OF    THE    RECTUM. 

Partial  excision  would  be  usually  a  more  correct  term  in  the  great 
majorit}^  of  cases,  but  as  by  the  sacral  route,  first  brought  before  the 
notice  of  the  profession  b}*  Kraske,  the  rectum  has  been  removed  up  to 
the  sigmoid  flexure,  I  retain  this  heading.  Under  it  the  following 
operations  will  be  considered :  (i)  Excision  from  the  perinseum, 
(ii)  Kraske's  operation  and  its  modifications,  (iii)  Excision  by  the 
vagina,  (ivj  Excision  by  abdominal  section,  (y)  Excision  by  the 
abdomino-perinseal  method. 

Indications.  Suitable  cases,  i.  Malignant  disease  of  anus — e.;/., 
papillomata  or  a  neglected  fistula,  or  condylomata  becoming  epithelio- 
matous.  2.  Rarely  non-malignant  stricture  and  ulceration  may  be 
treated  in  this  way  instead  of  by  dilatation,  but  only  in  cases  where 
extensive  ulceration  exists  with  multiple  points  of  stenosis,  and  the  use 
of  the  bougie  is  found  to  be  ineffectual.  3.  Malignant  disease  of  the 
rectum.  Of  the  points  which  have  to  be  now  considered,  the  extent  of 
the  disease  is  the  most  important.  A  growth  that  is  limited  to  the 
rectum,  at  whatever  part  it  may  be  situated,  and  however  high  it  may 
extend  along  the  course  of  the  bowel,  may  be  removed  by  one  of  the 
methods  about  to  be  described.  Extension  beyond  the  rectum  to  sur- 
rounding parts,  as  shown  by  fixity  of  the  growth  to  the  sacrum  on  the 
one  hand,  or  to  the  bladder,  vagina,  or  uterus  on  the  other,  constitutes 
a  contra-indication  to  au}^  attempt  at  a  radical  operation.  The  amount 
of  fixit}-  may,  however,  be  most  difficult  to  estimate. 

The  administration  of  ether  or  A.C.E.  may  help  here  as  well  as  in 
deciding  the  extent  of  the  disease.  The  parts  where  it  is  most  difficult 
and  important  to  estimate  the  mobility  are  the  neighbourhood  of  the 
prostate,  urethra,  and  the  neck  of  the  uterus.  Mr.  Cripps  thinks  that 
though  the  bowel  in  contact  with  the  prostate  may  be  diseased,  it  is 
a  long  while  before  the  prostate  itself  becomes  infected ;  in  women,  on 
the  contrary,  when  the  disease  is  on  the  anterior  part  of  the  bowel,  the 
vagina  and  uterus  quickly  become  implicated.  The  recto-vaginal  septum, 
if  involved  in  its  lower  part,  may  be  cut  away,  but  the  patient  will  be 
liable  to  find  fgeces  getting  into  the  vagina,  especially  when  the  bowels 
are  loose.  The  condition  of  the  glands,  sacral,  iliac,  and  inguinal,  Avill, 
of  course,  be  examined,  and  the  possibility  of  deposits  in  the  liver 
remembered. 

Glandular  infiltration  is  said  by  several  to  occur  late  in  rectal  carci- 
noma.    This,   at  first  sight  a  point  which  may  favour  operation,    is 


EXCISION  OF  THE  RECTUM.  499 

counterbalanced  by  the  well-known  fact  that  rectal  carcinoma  is  fre- 
quently insidious,  and  that  thus,  by  the  time  it  has  pronounced  its 
existence,  it  is  already  in  an  advanced  stage. 

Finally,  the  age  of  the  patient,  this  being  not  judged  of  by  years  alone. 
the  condition  of  the  kidneys  and  other  viscera,  whether  the  general 
condition  and  reparative  powers  are  sufficiently  good  to  meet  the  calls 
of  what  may  be  a  very  severe  operation,  must  all  be  taken  into  careful 
consideration. 

Miich  information  bearing  on  the  value  of  excision  of  the  rectum  will 
come  out  if  we  institute  a  comparison  between  Excision  of  the 
Becttun  and  Colotomy.  The  chief  points  calling  for  attention  are — 
(i)  The  mortality  of  the  operation,  (ii)  The  duration  of  life  after  it. 
(iiij  The  amount  of  comfort  given  by  it. 

.  (i)  TJte  Mortality  of  the  Operation. — In  making  a  comparison  on 
this  head  between  colotomy  and  excision  of  the  rectum,  one  important 
point  must  always  be  remembered — i.e..  that  the  latter  operation  is 
never  performed  under  those  unfavourable  conditions  of  obstruction 
which,  o^^'ing•  to  the  operation  being  often  deferred  till  too  late,  render 
the  mortality  of  colotomy  such  a  high  one.  Turning  to  the  mortality  of 
excision  by  itself,  without  comparison  with  any  other  operation,  we  find 
that  McCosh,  in  1892  (Xeic  Yorl-  Med.  Journ..  Sept.  3),  collected  439 
cases  Avith  84  deaths,  a  mortality  of  19*1  per  cent.  Later.  Kraske  (Ann. 
of  Surij.,  vol.  ii.  1897,  p.  380)  gives  a  mortality  of  9*8  per  cent.,  or 
5  deaths  in  51  cases  operated  upon  during  the  years  1890 — 1897,  and 
Paul  (Ijancet,  vol.  ii.  1897.  p.  jS)  publishes  a  series  of  zS  cases  with 
4  deaths,  i.e.,  a  mortality  of  I4"2  per  cent. 

In  this,  as  in  every  other  comparatively  novel  and  important  opera- 
tion, a  very  large  number  of  unsuccessful  cases  will  remain  unpublished, 
whilst  nearly  every  successful  case  is  reported  at  once.  The  real  death- 
rate,  therefore,  when  the  facility  with  which  shock,  hemorrhage,  cellu- 
litis, peritonitis  may  occvu-  in  a  part  which  cannot  be  kept'  absolutely 
aseptic,  and  in  patients  no  longer  young  and  the  subjects  of  rectal 
cancer,  is  fairly  estimated,  lies  probably  between  15  and  20  per  cent. 
Nor,  when  we  consider  how  limited  man's  capacity  for  bearing  grave 
operations  remains,  however  much  we  have  advanced  in  surgery,  is  it 
at  all  probable  that  the  death-rate  will  fall  much  below  20  per  cent., 
if  all  cases  operated  on  are  honestly  reported.  When  we  consider  the 
mortality  of  inguinal  colotomy  for  rectal  cancer,  excluding  the  cases 
where  colotomy  is  performed  under  the  most  unfavourable  circumstances 
of  obstruction,  in  other  words  "  the  too  late  cases."  the  mortality  will  be 
distinctly  less,  varying  from  under  5  to  under  10,  accordingly  as  the 
operation  is  performed  by  operators  of  especial  experience  or  otherwise. 
Here,  too.  the  value  of  statistics  is  greatly  impaired  by  the  tendency  to 
publish  only  successes.  But  there  can  be  no  doubt  whatever  that 
colotomy  in  cases  uncomplicated  by  obstruction  is  most  distinctly  a 
safer  operation  than  excision  of  the  rectum  from  the  perineum,  and,  (? 
fortiori,  than  the  severer  methods. 

(ii)  Ihiration  of  Life. — With  regard  to  this  point,  I  think  a  larger 
number  of  cases  will  show  that  if  the  surgeon  decides  to  advise,  and  the 
patient  is  willing  to  run  the  risk  of,  the  more  serious  operation,  the 
prolongation  of  life  will  be  greater  here  than  after  colotomy.  if  the  cases 
are  wisely  selected.      I  think  that  the  above  is  borne  out  by  the  results 


500  OPERATIONS  ON  THE  ABDOMEN. 

of  the  statistics  which  we  have.  It  is  rare  for  patients  after  colotomy 
for  carcinoma  to  survive  more  than  one  jeav  and  a  half.  Making  due 
allowance  for  the  advanced  date  at  which  cases  of  rectal  cancer  too  often 
come  under  treatment,  for  the  fact  that  excision  will  usually  be  per- 
formed in  selected  cases,  and  that  thus  colotomy  will  be  reserved  for 
those  less  favourable,  I  think  the  published  cases  of  excision  show  a 
greater  prolongation  of  life. 

Yolkmann  (Sammlung  Klin.  Vortriuje,  May  13,  1878)  claimed  three 
complete  cures  and  several  cases  of  very  late  recurrence — viz.,  one  after 
6  years,  one  after  5,  and  one  after  3.  One  case  died  of  carcinoma  of  the 
liver  8  vears  after  operation  without  local  recurrence,  and  one  case 
remained  well  1 1  3^ears  after  the  removal  of  a  large  mass  reaching  high 
up  ;  in  this  case  recurrence  occurred  twice  in  the  scar,  and  was  removed. 
Czerny's  experience  is  also  very  good.  Two  of  his  cases  had  survived 
the  operation  over  4  years,  one  3  years  and  4  months  ;  three  others  were 
well  after  intervals  of  at  least  2  years  (Henck,  Arcli.  f.  Klin.  Chir.. 
Bd.  xxix.  Hft.  3).  Mr.  Ball  (Dis.  of  the  Rectum  and  Anus,  2nd  ed. 
p.  364)  has  had  one  patient  alive  and  well  9  years  and  another  6  years 
after  operation.  Mr.  Cripps  (loc.  sup'a  cit.)  has  had  one  case  free  from 
recurrence  12  years,  two  6  years,  one  5  years,  two  4  years,  one  3  years 
after  operation.  More  recently,  Kraske  (loc.  supra  cit.),  in  the  series 
of  fifty-one  cases  above  referred  to,  states  that  sixteen  patients  died 
from  intercurrent  disease,  without  signs  of  recurrence  or  metastasis,  at 
times  varying  from  i  ^  to  5  years  after  the  operation,  and  fifteen  patients 
are  alive  and  free  from  recurrence  f  of  a  year  to  8^  years  after  the 
operation.  Keen  {Titer.  Gaz.,  April  1897)  gives  the  results  of  twelve 
cases  which  survived  the  operation  ;  four  had  passed  the  4-year  limit, 
and  two  others  had  nearly  reached  it,  without  recurrence. 

(iii)  Amount  of  Comfort  Afforded. — After  this  operation,  as  after 
excision  of  the  larynx,  a  distinction  must  be  drawn  between  mere 
survival  and  what  deserves  the  name  of  recovery.  The  amount  of  com- 
fort enjoyed  by  the  patient  will  depend  on  :  (i)  The  amount  of  contrac- 
tion that  takes  place.  (2)  How  far  he  has  control  over  his  motions. 
The  patient  should  always  be  warned  about  these  sequelae.  If  he  does 
not  keep  under  observation,  and  contraction  follows,  I  consider  his  case 
will  compare  most  unfavourably  with  that  after  a  well-performed  colo- 
tomy, and  may  even  be  as  bad  as  that  of  a  patient  with  advanced  rectal 
cancer,  (i)  Where  the  whole  circumference  of  the  bowel  has  been  re- 
moved, a  matter  referred  to  below  (p.  505),  it  is  obvious  that  there  must 
be  a  great  risk  of  contraction  in  the  scar  tissue  which  replaces  the  mucous 
membrane.  This  contraction  forms  a  most  serious  difficulty  in  the  after- 
treatment,  and  is  liable  to  lead  to  most  unsatisfactory  results.  The 
more  the  connective  tissue  around  the  bowel  is  interfered  with,  the 
more  profuse  the  suppuration  and  the  longer  the  healing,  the  more 
marked  will  the  contraction  be.  Colotomy  has  been  required  for  it,  as 
occurred  in  a  case  under  my  care,  where  excision  of  the  rectum  had 
been  performed  elsewhere.  The  above  risk  may  be  obviated,  no  doubt, 
by  drawing  down  the  bowel  and  suturing  it  to  the  skin ;  but  this  step 
(p.  505)  is  not  often  feasible,  especially  in  men,  and  if  sutures  are 
inserted  they  cut  through  quickly  (vide  infra).  The  severed  end  of  the 
bowel  is  drawn  considerably  downwards  during  the  process  of  healing. 
This  renders  it  easier  for  the  patients  to  pass  a  bougie  from  time  to 


EXCISIOX  OF  THE  RECTUM.  50I 

time,  the  need  of  which  must  be  firmly  impressed  upon  them.  Another 
means  of  securing  the  patency  of  the  bowel  is  by  wearing  a  vulcanite 
tube,  as  recommended  by  Mr.  AUingham.  These  are  three  or  four 
inches  long,  with  one  end  conical,  and  with  the  other  ending  in  a 
broadish  flange  to  prevent  its  slipping  into  the  bowel,  and  also  to  enable 
it  to  be  stitched  to  a  bandage  which  keeps  it  in  place.  Patients  begin 
to  wear  it  about  a  fortnight  after  the  operation,  and,  save  for  taking  it 
out  when  the  bowels  act,  retain  it  constantly  for  some  months,  some 
having  to  wear  it  for  the  rest  of  their  lives. 

(2)  As  to  the  power  of  retaining  faeces,  incontinence  is  always  present 
at  first,  but  control  is  usually  regained  after  a  time,  save  where  the 
motions  are  loose.  Mr.  Cripps  (loc.  supra  cit.)  states  that  incontinence 
was  present  in  only  seven  out  of  thirty-six  cases  which  he  collected. 
Torsion,  after  the  advice  of  Gersuny  (vide  infra),  as  a  preventive  when 
the  entire  circumference  of  the  bowel  and  the  sphincters  have  been 
removed,  has  proved  satisfactory  in  some  cases  (p.  512). 

Operation. 

The  preliminary  treatment  is  most  important.  The  patient  should  be 
kept  in  bed  for  several  days  before  the  operation,  and  the  strength  and 
general  condition  improved  as  much  as  possible  by  the  administration  of 
plenty  of  light,  easily  digested  and  nutritious  food.  The  rectum  and 
large  intestine  should  also  be  efticiently  emptied  by  means  of  mild 
purgatives  and  daily  enemata.  If  the  growth  causes  marked  obstruction 
to  the  passage  of  fteces  or  to  the  efficient  administration  of  enemata, 
lavage  of  the  bowel,  by  means  of  a  long  rectal  tube  passed  through  the 
stricture,  should  be  made  use  of.  In  order  to  promote  rapid  healing  and 
prevent  suppuration,  as  much  as  possible,  every  effort  should  be  made  to 
render  the  bowel  as  little  septic  as  possible.  To  this  end  intestinal 
antiseptics,  such  as  resorcin,  salol,  &c.,  may  be  administered  by  the 
mouth,  and  weak  antiseptic  solutions  used  for  lavage  and  for  the 
enemata.  Where  a  rapid,  soft  growth,  quickly  ulcerating,  has  given 
rise  to  a  foul  discharge,  Dr.  E.  H.  Taylor  (Ann.  of  Surg.,  vol.  i.  1897, 
p.  385)  recommends  curetting  as  a  preliminary  measure,  in  order  to 
bring  about  a  sweeter  condition  of  the  growth  and  surrounding  parts. 
He  makes  use  of  a  flushing  spoon  for  this  purpose,  and  finds  that 
the  hgemorrhage  is  "trivial,  and  soon  ceases."  On  the  other  hand, 
Kraske  considers  that  this  should  be  done  only  exceptionallj^.  as  it  is 
not  without  danger. 

With  regard  to  the  cjuestion  of  performing  colotomy  before  the 
excision  of  the  growth,  the  opinions  of  authorities  differ.  Kraske  only 
makes  use  of  it  when  the  growth  is  causing  obstruction,  and  so  prevents 
efficient  emptying  of  the  bowel  before  operation.  He  then  makes  the 
artificial  anus  in  the  transverse  colon,  as  being  less  likely  to  interfere 
with  the  subsequent  operation  and  more  easy  to  close  later.  On  the 
other  hand,  M.  Quenvi,  quoted  by  Taylor  (loc.  supra  cit.),  always  performs 
a  preliminary  inguinal  colotomy,  usually  about  twelve  days  before  the 
main  operation.  Keen  (Journ.  Amer.  Med.  Assoc,  1898)  also  is  in 
favour  of  a  colotomy,  and,  moreover,  makes  the  artificial  anus  a  per- 
manent one,  by  closing  the  upper  end  of  the  divided  rectum  after 
removal  of  the  growth.  The  chief  objections  to  a  preliminary  colotomy 
are  that  it  causes  loss  of  valuable  time  without  a  compensating  advan- 
tage,  since,    with    careful    preliminary    evacuation    of  the   bowel,    the 


502 


OPERATIONS  ON  THE  ABDOMEN. 


operation  and  the  after-course  are  quite  satisfactory  without  it ;  that  it 
saps  the  patient's  strength  and  so  diminishes  his  power  of  standing  the 
more  severe  operation,  and  that,  by  fixing  the  bowel  above,  it  may  inter- 
fere with  its  mobilit}^  thus  preventing  it  from  being  efficiently  pulled 
down  at  the  second  operation.  It  would  seem,  therefore,  that  the  wisest 
course  lies  in  reserving  colotomy  for  those  cases  in  which  there  is  either 
declared  or  threatened  obstruction,  preventing  the  proper  evacuation  of 
the  bowel  before  the  gro^vth  is  excised. 

The  most  suitable  operation  in  a  given  case  will  vary  according  to  the 


position  and  extent  of  the  growth. 


For  a  growth  involving  the  lowest 


two  inches  of  the  rectum  the  operation  by  a  perineal  incision  will 
usually  suffice ;  for  more  extensive  growths,  Kraske's  method  or  one  of 
the  modifications  of  that  operation,  will  generally  be  necessary.  Finally, 
for  a  few  rare  cases  in  which  the  growth  is  situated  very  high  up  in  the 
rectum,  the  combined  perinseal  and  abdominal  method  will  be  reqiiired. 

Fig.   193. 


1/    '  ^,^ 
(Allingham.) 

Perinseal  Excision  of  Rectum  in  its  Entire  Circumference. — 
The  patient  is  placed  in  lithotomy  position,  and  the  surgeon  makes  an 
oval  incision  into  both  ischio-rectal  fossae,  around  the  bowel,  then 
prolongs  this  oval  incision  backwards  so  as  to  reach  the  coccyx 
(Fig.  193). 

This  backward  prolongation  is  much  needed  in  order  to  give  addi- 
tional room  for  meeting  hgemorrhage,*  and  for  providing  drainage  later 
on.  The  fingers,  aided  if  needful  by  the  knife  or  blunt  dissector, 
separate  the  bowel  at  the  sides  and  posteriorly  as  high  as  the  levator 
ani ;  the  haemorrhage  is  usually  not  severe,  and  can  be  readily  arrested 

*  If  this  incision  has  to  be  carried  as  high  up  as  three  or  four  inches,  the  haemor- 
rhage will  be  free,  as  the  superior  hsemorrhoidal  artery  here  divides  into  two  terminal 
branches.  A  sufficient  incision,  well  opened  out  with  large  retractors,  will  admit  of 
easily  dealing  with  this  vessel.  Another  method  is  to  begin  by  a  free  posterior  in- 
cision, made  by  guiding  a  curved  sharp  bistoury  well  above  the  disease  in  the 
posterior  wall,  bringing  out  the  point  at  the  tip  of  the  coccyx,  and  then  cutting  all 
the  intervening  tissues  into  the  bowel.  This  exposes  well  the  limits  of  the  growth, 
but  causes  more  bleeding.  If  the  first  method  is  made  use  of,  the  bowel  must  be  laid 
open  subsequently,  to  investigate  the  upper  limits  of  the  disease. 


EXCISION  OF  THE  EECTU3I. 


503 


by  pressure-forceps,  sponges  pushed  into  the  incision,  and  by  operating 
as  rapidly  as  is  consistent  \^'ith  safety.  Taylor  (Joe.  supra  cit.)  recom- 
mends that  the  posterior  incision  should  be  made  first,  and  then  the 
lateral  ones  in  the  following  manner,  in  order  to  better  preserve 
the  sphincteric  apparatus,  and  thus  prevent  incontinence  afterwards. 
••  Begin  by  a  median  posterior  incision  behind  the  anal  margin  and 
extend  it  backwards  in  the  middle  line  over  the  coccyx.  Then,  start- 
ing from  the  tip  of  this,  follow  the  median  raphe  forwards,  splitting  the 
posterior  part  of  the  external  sphincter  and  separating  the  levatores  ani. 
On  introducing  the  index  finger  into  the  wound,  the  rectum  is  easily 
cleared  on  its  posterior  and  lateral  aspects.  Strong,  blunt-pointed 
scissors  are  now  taken,  one  blade  is  placed  in  the  wound  just  behind 
the  anus,  and,  in  the  interval  between  the  rectum  and  the  levator  ani, 
the  other  blade  rests  upon  the  skin.  The  bridge  of  tissue  between  the 
blades  is  now  cut,  and  a  similar  section  made  upon  the  opposite  side." 

Fig.  194. 


(AUiughain.) 


The  adoption  of  this  plan  \\\\\  be  found  to  materially  facilitate  the 
separation  of  the  bowel,  in  addition  to  saving  the  levator  ani  muscles. 

The  separation  of  the  bowel  in  front  varies  with  the  sex  of  the 
patient.  In  a  male,  a  full-sized  metal  sound  having  been  passed  into 
the  bladder  and  kept  well  hooked  up  under  the  pubes,*  the  surgeon 
carefully  dissects,  partly  with  his  finger  and  partly  with  scissors, 
between  the  bowel  and  urethra  and  prostate.  These  parts  are  natur- 
ally adherent,  and  this  dissection  must  be  carefully  conducted,  as  any 
opening  into  the  bladder  or  urethra  will  much  increase  the  shock.  If 
the  left  index  be  kept  in  the  rectum  and  the  thumb  just  outside  it,  they 
will  serve  to  pull  the  bowel  as  it  is  freed  away  from  the  urinary  tract, 
while  the  operator  is  at  the  same  time  kept  informed  how  near  to  the 
bowel  he  is  cutting  (Fig.  195).  In  the  case  of  a  woman  the  surgeon's 
left  index,  or  the  fino-er  of  an  assistant  in  the  vagina,  will  ofive  the  best 


*  Prof.  Macleod  advises  that,  if  the  disease  is  low  down,  it  matters  little  whether 
the  bladder  is  full  or  empty ;  if  a  higher  portion  has  to  be  dealt  with,  as  Dupuytren 
showed,  the  urine  should  be  retained,  so  as  to  raise  the  recto-vcsical  pouch. 


504 


OPERATIONS  ON  TIIE  ABDOMEN. 


warning  of  his  knife  or  scissors  (the  latter,  long  and  blunt-pointed,  are 
preferable)  getting  too  near  the  vaginal  mucous  membrane.*  If  this 
be  encroached  upon,  it  must  be  removed  without  hesitation,  in  the 
hope  that  the  cloaca  thus  formed  will  be  much  diminished  by  con- 
traction, or  that  it  may  be  closed  subsequently.  If  the  disease  has 
extended  up  the  recto- vaginal  septum,  the  peritonaeum  must  be  looked 
out  for,  and  the  greatest  care  taken  not  to  open  this  cavity  at  the  upper 
part  of  the  dissection.  If  this  should  occur,  an  aseptic  sponge  must  be 
kept  over  the  opening.  The  levator  ani  being  carefully  cut  through, 
the  rectum,  now  separated  everywhere  save  above,  is  dragged  down  by 
an  assistant  or  by  the  operator  with  his  left  hand.  While  this  tension 
is  kept  up,  the  surgeon  with  his  finger,  aided  by  scissors,  frees  the 
bowel    sufficiently  above   the  disease  to  admit   of  dividing   it  safely. 

Fig    195 


(Allingliam.) 


Frequent  examination  of  the  interior  of  the  bowel  should  be  made  at 
this  stage  to  tell  when  the  upper  limit  of  the  disease  has  been  reached. 
The  rectum  should  be  divided  at  least  an  inch  above  this  point.  Before 
the  bowel  is  cut  away,  the  upper  end  should  be  secured  with  a  vulsel- 
lum,  for  fear  that  it  may  retract  and  cany  anj^  still  bleeding  points  out 
of  reach. 

When  the  bowel  has  been  safel}^  isolated  above  the  disease,  it  must 
be  divided  with  scissors.  These  are  greatly  to  be  preferred  to  the 
ecraseur,  as  they  give  a  much  more  cleanly  cut  surface,  and  one  there- 
fore less  liable  to  slough,  and  they  furthermore  avoid  the  risk  which  is 
inseparable  from  the  use  of  the  ecraseur — viz.,  its  gradually  encroach- 
ing, as  it  is  tightened,  more  and  more  closely  upon  the  diseased  area. 

One  objection  to  the  division  of  the  rectum  with  a  Paquelin's  cautery 
is,  as  remarked  by  Mr.  Cripps,  that  the  use  of  any  form  of  cautery 
during  the  operation  makes  it  exceedingly  difficult  to  distinguish 
between  the  hard  nodules  of  burnt  tissue  and  portions  of  the  disease 
which  may  be  left  behind. 


Subsequent  sloughing  here  is  not  unlikely. 


I 


EXCISION  OF  THE   RECTUM.  505 

The  bowel  haviiig'  been  removed,  bleeding  points  *  are  most  carefully 
looked  for,  and  the  wound,  thoroughly  irrigated  and  dusted  over  with 
iodoform.! 

If  the  peritonteum  has  been  injured  and  the  opening  is  too  large  fur 
suturing,  either  a  drainage-tube  packed  around  with  gauze  (Barden- 
hauer),  or  a  tam]>on  of  gauze,  must  be  made  use  of. 

Mr.  Cripps  considers  that  any  attempt  to  bring  down  the  cut  edges 
of  the  rectum,  and  to  stitch  them  in  situ  around  the  anus,  is  perfectly 
useless,  as  the  sutures  are  certain  to  cut  their  way  out,  and  harmful, 
as  likely  to  prevent  the  escape  of  discharges.  As  this  entails  the  very 
serious  risk  of  septicaemia,  the  advantage  Avhich  suturing  the  bowel 
woiTld  give,  if  it  were  safe,  of  preventing  subsequent  contraction 
(p.   500)  has  been  put  aside. 

On  the  other  hand,  Volkmann,  Czerny  (he.  supra  cit.)  and  others 
have  recommended  the  use  of  sutures  so  as  to  hasten  healing  and 
obviate  the  tendency  to  stricture.  If  they  are  employed,  they  must 
be  passed  as  advised  by  Ball,  not  only  through  skin  and  bowel,  but 
also  deeply  through  the  surrounding  pelvic  structures  as  well  ;  drainage- 
tubes  should  also  be  inserted  here  and  there  between  the  sutures. 
Superficial  sutures  are  then  put  in  as  well,  so  as  to  further  diminish 
the  strain.  If  these  precautions  are  taken,  if  no  fiecal  contamination  of 
the  wound  has  occurred,  if  antiseptic  precautions  have  been  taken 
throughout,  and  if  the  wound  has  been  rendered  thoroughly  dry  and 
bloodless,  the  eraplovment  of  sutures  deserves  a  trial  in  appropriate  cases. 

Mr.  Bidwell  (Brit.  Med.  Journ.,  Oct.  21,  1899)  recommends  the 
following  plan  to  enable  the  edges  of  the  wound  to  be  brought  together. 
Two  transverse  incisions  about  two  inches  long  are  made  on  each  side  of 
the  perinseal  incision.  The  flaps  of  skin  so  formed  are  then  dissected 
up  and  attached  to  the  cut  edge  of  the  rectum  by  means  of  silkworm 
gut  sutvires.  As  a  rule,  this  can  be  carried  out  without  undue  tension, 
but  should  there  be  an}*,  a  longitudinal  incision  in  the  posterior  surface 
of  the  rectum  will  enable  the  union  to  be  effected. 

If  the  growth  reaches  the  skin  of  the  anus  the  inguinal  lymphatic 
glands  must  be  carefully  examined,  and,  if  found  enlarged,  they  must 
be  removed  either  at  once  or  at  a  second  operation.  If  the  bowel 
cannot  be  sutured  in  the  position  of  the  anus,  Taylor  (loc.  supi'cc  cit.) 
recommends  that  "it  be  drawn  backwards  in  the  middle  line  between 
the  levatores  ani  and  a  subcoccygeal  anus  formed.  The  wound  in 
front  is  then  closed  by  deep  sutures.  As  Mr.  Ball  points  out,  they 
have  the  great  advantage  of  not  leaving  recesses  about  the  rectum  in 
which  serum  might  collect  and  decompose.  These  deep  sutures  should, 
of  course,  include  the  levatores  ani ;  our  object  being  to  reconstruct  a 
sphincteric  apparatus." 

Question  of  partial  removal. — If  any  of  the  mucous  membrane, 
even  a  mere  strip,  can  be  safehj  left,  the  amount  of  subsequent  con- 
traction will  be  less ;  but  here,  as  in  all  other  operations  for  malignant 

*  If  the  patient's  strength  fail  towards  the  close  of  the  operation,  no  time  should 
be  lost  in  tying  the  vessels,  but  each  bleeding  point  should  be  secured  with  Spencer 
Wells's  forceps  ;  these  are  removed  in  twenty-four  or  thirtj'-six  hours. 

t  Throughout  the  operation  the  wound  should  be  well  syringed  with  a  solution 
mercury  perchloride  (i  in  4000).     This  should  be  used  very  hot  if  there  is  trouble 
some  oozinsr. 


506  OPERATIONS  ON  THE  ABDOMEN. 

disease,  every  consideration  must  give  way  to  the  chief  object,  that  of 
extirpating  the  gro\Hh. 

Partial  operations  should  be  reserved  only  for  cases  where  the  disease 
is  very  localised  in  amount,  and  admits  of  extirpation,  together  with 
a  very  wide  margin  of  bowel.  Where  the  disease  implicates  one-half 
of  the  bowel,  even  if  apparently  not  disseminated  in  the  mucous  mem- 
brane, the  whole  circumference  should  be  removed.  Mr.  Allingham 
thus  condemns  partial  operations :  "  The  partial  removal  of  the  cir- 
cumference of  the  bowel  is,  in  my  opinion,  most  unsatisfactory.  In 
all  the  cases  in  which  I  have  removed  only  part  of  the  wall  there  has 
been  either  a  return  of  the  disease  in  the  rectum,  or  in  the  glands  in 
the  groin,  or  in  some  internal  organ,  mostly  the  liver." 

If  the  surgeon  decide  on  a  partial  operation,  he  must  be  prepared 
for  some  increased  difficulty,  owing  to  the  diminished  room  for  working, 
and  meeting  the  hsemorrhage.  Perhaps  only  one  semilunar  incision 
around  the  anus  will  be  required. 

Kraske's  Operation  and  its  Modifications  (Fig.  199). — Kraske.  of 
Freiburg  (Arch.  f.  Klin.  G/iir.,  Bd.  xxxiii.  S.  563},  introduced  this 
route  as  best  adapted  for  those  cases  which,  in  Volkmann's  words,  are 
situated  too  high  for  the  perinaeal  route  and  are  too  low  and  too  fixed 
to  admit  of  removal  by  abdominal  section.  It  will  be  imdei'stood  by 
all  that  this  is  an  operation  of  great  severity,  and  only  justifiable  when, 
as  compared  with  colotomy,  the  risks  on  the  one  hand,  and  the  advan- 
tage on  the  other,  of  attempting  a  radical  cure,  and,  at  all  events, 
affording  a  greater  prolongation  of  life  (p.  499),  have  been  fairly  put 
before  the  patient  or  the  friends.  Again,  it  is  onl}^  a  surgeon  who  has 
had  large  operating  experience  who  should  undertake,  and  only  patients 
who  have  sufficient  reparative  power  who  should  be  submitted  to,  any 
of  these  operations  of  excision  of  the  rectum,  more  particularly  to  this 
and  the  ones  that  follow.  For  at  least  four  days  before  the  operation 
the  patient  should  be  prepared  by  aperients  and  enemata  and  a  wisely 
restricted  fluid  diet.*  The  parts  having  been  previously  shaved  and 
cleansed,  the  latter  process  is  repeated  when  the  patient  is  passing 
under  the  ana3sthetic,  and  the  bowel  cleansed  as  high  up  as  possible 
by  irrigation  with  lot.  hydr.  perch,  (i  in  5000),  and  with  swabs  of 
iodoform  gauze  on  long  forceps.  Dr.  Kelsey  insists  upon  this,  as  it 
may  be  of  the  greatest  help  to  be  able  to  introduce  the  finger  into  the 
bowel  during  the  operation  :  "  Exactly  in  proportion  to  the  thorough- 
ness of  this  disinfection,  and  to  the  care  with  wliich  the  wound  is  kept 
clean  during  every  stage  of  the  operation  will  be  the  mortality."  A 
small  tampon  of  iodoform  gauze  may  be  left  in  the  rectum,  but  too 
large  a  mass  obscures  palpation  of  the  diseased  part  from  the  incision. 
The  patient  may  be  on  his  right  side  as  recommended  by  Kraske,  or  on 
his  face,  or,  again,  in  the  lithotomy  position,  according  to  the  conveni- 
ence of  the  operator.  If  tlie  thighs  are  kept  well  flexed,  and  a  sand 
pillow  is  placed  under  the  lumbar  spine,  it  will  be  found  that  the 
lithotomy  position  is  very  suitable,  the  intestines  in  this  position  fall- 
ing away  from  the  recto-vesical  pouch,  the  separation  of  the  peritonaeum 

*  Dr.  C.  B.  Kolsey  (^Ncw  York  Med.  Journ.,  vol.  ii.  1895,  p.  457)  advises  that  a  dose 
of  morphine  and  bismuth  should  be  given  on  the  evening  before,  and  repeated  a  few 
hours  before  the  operation.  The  paper  is  au  excellent  one,  full  of  practical  hints 
from  which  I  have  borrowed  largely. 


EXCISIOX  OF  THE  RECTUM. 


507 


being  thus  facilitated,  and  moreover  the  light  coming  from  above,  the 
deep  wound  will  be  well  illuminated,  and  the  whole  of  its  extent  well 
under  the  eye  of  the  operator.  Whatever  be  the  position,  the  pelvis 
should  be  elevated,  so  as  to  diminish  haemorrhage.  An  incision  is  then 
made  in  the  middle  line  from  the  posterior  edge  of  the  anus  to  the 
centre  of  the  sacrum,  the  knife  being  carried  down  to  the  bone  at  once. 


Fig.   196. 


From  a  dissection  made  by  Mr.  E.  H.  Tat/lor. 

The  black  dotb  over  the  sacrum  indicate  the  levels  of  tlie  first,  second,  third, 
and  fourth  posterior  sacral  foramina. 


1.  Gluteus  maximiis  muscle. 

2.  Sciatic  artery. 

3.  Great  sacro-sciatic  ligament. 

4.  Levator  ani. 

5.  Sphincter  ani  externus. 


6.  Pyriformis  muscle. 

7.  Lesser  sacro-sciatic  ligament. 
S.  Coccj'geus  muscle. 

g.  Internal  pudic  artery  and  x)udic  nerve. 
ID.  Obturator  interuus  muscle. 


A  flap  on  the  left  side  is  then  turned  outwards,  including  a  part  of  the 
gluteus  maximus,  and  exposing  the  side  of  the  sacriam  and  the  sacro- 
sciatic  ligaments.  These  last  must  be  divided  and  detached  from  both 
sides  of  the  coccyx  and  the  left  side  of  the  sacrum,  together  with  the 
coccygeus,  part  of  the  left  pyriformis  and,  if  the  anal  region  is  to  be 
removed,  the  sphincter  and  levator   ani.     With  a  periosta3al  elevator 


5o8 


OPERATIONS  ON  THE  ABDOMEN. 


passed  under  the  sacrum  the  soft  parts  are  now  detached  from  the 
hollow  of  this  bone,  including  the  sacra  media  vessels  and  a  venous 
plexus,  thus  avoiding  troublesome  bleeding.  The  surgeon  must  now 
decide  how  much  bone  requires  removal.  Reference  to  the  lines  of 
bone-section  indicated  in  Fig.  199  will  show  the  extent  to  which  bone 

Fig.  197. 


From  a  dissection  made  hj  Mr.  E.  H.  Taylor 

The  black  dots  over  the  sacrum  indicate  the  levels  of  the  first,  second,  and  third 
posterior  sacral  foramina. 


1.  Lateral  sacral  artery. 

2.  Middle  sacral  artery. 

3.  Superior  hsemorrlioidal  artery  (left 

main  division). 

4.  The  pelvic  peritouieum. 

5.  Lesser  sacro-sciatic  ligament. 

6.  Pelvic  fascia. 


7.  Gluteus  maximus  muscle. 

8.  Levator  ani. 

g.  Sphincter  ani  externus. 

10.  Sacral  canal. 

11.  Lateral  sacral  artery. 

12.  Rectum. 

13.  Middle  hasmorrlioidal  artery. 


is  removed  in  Kraske's  original  operation,  and  in  some  of  the  chief 
modifications  of  this.  No  hard-and-fast  lines  can,  however,  be  laid 
down,  since  the  amount  of  room  required  and  therefore  the  amount 
of  bone  which  must  be  removed,  must  depend  entirely  upon  the  extent 
of  the  growth  and  the  size  of  the  outlet  of  the  pelvis.     Kraske   {loc. 


EXCISION  OF  THE  RECTUM. 


509 


supra  Git.  p.  499)  does  not  now  recommend  removal  of  any  bone 
)3ey ond  the  coccyx  except  when  this  is  necessary  in  order  to  get 
sufficient  room.  Senn  (PJnlad.  Med.  Journ.,  Sept.  30,  1899)  i^^s 
come  to  the  conclusion  that  resection  of  the  sacrum  is  not  only  need- 

FiG.  19S. 


From  a  dissection  made  by  Mr.  E.  H.  Taylor. 

The  black  dots  over  the  sacrum  indicate  the  levels  of  the  first,  second,  and  third 

posterior  sacral  foramina. 
I.  The  sacral  canal. 


2.  The  pelvic  peritonaeum. 

3.  The  rectum. 

4.  The  ureter. 

5.  Middle  haemorrhoidal  artery. 

6.  Vas  deferens. 

7.  Seminal  vesicle. 

8.  Pelvic  fascia,   clothing  the  upper 

surface  of  the  levator  ani. 


9.  Cut  surface  of  the  ano-coccygeal 
raphe. 

10.  The  pelvic  peritonffium. 

11.  The  bladder. 

12.  Superior    haemorrhoidal     artery 

(right  division). 

13.  Pelvic  fascia  (i-ecto-vesical  layer). 

14.  Cut  surface  of  the  auo-coceygeal 

raphe. 


less,  but  absolutely  harmful,  and  maintains  that  removal  of  the  cocc3tc 
only  will  always  be  sufficient.  The  coccj^x  should  therefore  be  removed 
in  the  first  instance ;  if  then  the  amount  of  space  obtained  is  found  to 
be  insufficient,  resection  of  the  sacrum  must  be  resorted  to.     Taylor 


5IO 


OPERATIONS  OX  THE  ABDOMEN. 


(he.  siqira  cU.)  advocates  temporary  sacral  resection,  as  first  practised 
hj  Heinecke,  and  later  by  Rehn  and  Rydygier,  chiefly  on  the  ground 
that  this  prevents  the  loss  of  posterior  support  of  the  levatores  ani 
which  results  from  permanent  resection.  The  chief  objections  to  this 
plan  are,  that  it  does  not  give  so  much  room,  that  the  bone-flaps  are 
liable  to  necrosis,  and  that  the  formation  of  a  sacral  anus  is  not  pos- 
sible. In  suitable  cases,  however,  such  as  the  successful  one  which  Taylor 
describes,  the  method  has  much  to  recommend  it,  but.  as  a  general  rule, 
it  will  be  found  that  sacral  resection  as  carried  out  by  Kraske  will  be 
as  efficient  as  the  more  complicated  methods,  and,  moreover,  is  more  rapid 
in  performance  and  more  suitable  for  the  formation  of  a  sacral  anus 
should  this  be  necessary.  The  soft  parts  being  vigorously  retracted  the 
surgeon  cuts  through  the  left  side  of  the  sacrum  along  a  curved  line 
(Fig.  199)  commencing  on  the  left  edge,  at  the  level  of  the  third 
posterior  sacral  foramen,  and  running  inwards  and  downwards  through 

the  fourth  foramen  to  the  left  corner 
of  the  sacrum.  By  cutting  along 
this  line  the  anterior  division  of 
the  third  sacral  nerve  will  not  be 
divided  nor  the  sacral  canal  opened. 
The  bleeding  up  to  this  time,  which 
is  largely  venous,  is  best  met  by 
firm  sponge  or  finger  pressure ;  much 
time  will  be  lost  in  attempting  to 
seize  the  bleeding  points  in  the  usual 
way.  As  soon  as  the  bone  is  out,  the 
vessels  may  be  closed  by  forci- 
pressure  or,  where  needful,  by  under- 
«.  The  iucisiun,  through  the  sacrum,  of  running.  The  haemorrhage  comes 
Kraske's  (p.  507).  a,  a'.  That  of  Barden-  chiefly  from  the  lateral  and  middle 
hauer,  who  takes  away  the  wiioie  lower  part  sacral,  the  hasmorrhoidal  arteries,  the 

bone  itself,  and  a  venous  plexus  on 
both  aspects  of  the  sacrum.  The  pelvis 
is,  in  this  way,  freely  opened,  and 
from  six  to  eight  inches  of  the  bowel 
may  be  removed.  The  tissues,  down  to  and  including  the  levatores  ani. 
are  now  divided  along  the  median  raphe  behind,  and  the  separation  of 
bowel  commenced.  If  the  growth  does  not  reach  to  within  an  inch  of 
the  external  sphincter,  this,  together  with  the  anus,  is  left  intact ;  if,  on 
the  other  hand,  there  is  any  suspicion  that  the  external  sphincter  and 
anal  region  may  be  involved  by  the  growth,  these  must  be  removed. 
Unless  matted  by  extension  of  the  disease,  the  bowel  will  readily  be 
shelled  out  of  its  bed,  posteriorly  and  laterally.  In  Dr.  Kelsey's  words 
(loc.  siqrra  cit.),  "  the  finger  cannot  be  passed  completely  under  and 
around  the  gut  on  account  of  its  size  at  this  point,  nor  can  it  be  drawn 
down  at  all  on  account  of  the  firm  attachments  of  the  peritonaeum  and 
the  meso-rectum.  Any  forcible  attempt  to  drag  it  down  at  this  stage 
is  attended  by  great  risk  of  rupture  and  consequent  soiling  of  the  wound, 
and  all  that  should  be  attempted  is  gentle  isolation  on  each  side  by 
separating  it  from  its  loose  attachments  with  the  finger,  and  discover- 
ing by  touch  the  extent  of  the  disease  to  be  removed,  which  can  gener- 
ally be   easil}^  done  by  palpating  the  tube  as  it   lies   in  the  wound." 


of  the  bone  as  far  as  the  third  sacral  fora 
miua.  /'.  Incision  of  v.  Volkmann  and  Eose 
which  passes  through  the  bone  at  a  higher 
level  still.    (Esmarch  and  Kowalzig.) 


EXCISION  or  THE  EECTUM.  511 

The  next  step  in  the  procedure  consists  in  the  division  of  the  bowel 
below  the  growth.  This  section  should  be  made  at  least  one  inch 
below  the  lower  margin  of  the  disease,  and  at  a  greater  distance  if 
there  is  any  doubt  as  to  the  extent  to  which  the  bowel  is  infiltrated 
with  growth.  Before  the  section  is  made  the  bowel  may  be  either 
encircled  just  below  the  growth  with  a  strong  silk  ligature,  or,  as 
recommended  by  Kraske,  sutures  ma}"  be  passed  through  the  upper  cut 
siirface,  or  again  the  bowel  may  be  clamped  with  forceps.  The  patient 
is  now  brought  into  the  lithotomy  position  (if  this  has  not  been  done 
already)  and  the  separation  of  the  bowel  continued.  This  is  carried 
out,  as  already  described  in  the  perin?eal  operation,  partly  by  blunt 
dissection  and  partly  by  means  of  scissors.  In  the  male,  a  full-sized 
sound  must  be  passed,  and  every  care  taken  in  separating  the  rectum 
from  the  prostate  and  bladder,  while,  in  the  female,  the  finger  of  an 
assistant  will  serve  as  a  guide  and  help  to  prevent  perforation  of  the 
posterior  wall  of  the  vagina  at  this  stage.  Soon  the  peritoneal  reflec- 
tion will  be  reached  on  the  anterior  wall ;  if  this  is  found  to  lie  well 
above  the  iipper  extremity  of  the  growth  it  may  be  possible  to  separate 
it  upwards  with  the  finger  to  the  desired  extent,  and  thus  avoid  opening 
the  peritonaeal  sac  altogether.  Should  '  it  be  found,  however,  that  the 
growth  extends  above  the  level  of  the  peritonasal  reflection,  it  will  not 
be  possible  to  separate  the  peritonaeum,  and  the  fold  should  then  be  at 
once  opened  freely.  The  bowel  is  now  held  from  coming  down  only  by 
the  meso-rectum.  This,  together  witli  the  pre-sacral  cellular  tissue  and 
contained  glands,  is  now  carefully  sej^arated  from  the  concavity  of  the 
sacrum  to  the  desired  extent,  gentle  traction  being  made  on  the  bowel 
while  this  is  being  done.  When  sufficient  of  the  bowel  has  been  freed 
and  brought  down  in  this  way,  it  is  clamped  one  inch  to  one  inch  and 
a  half  above  the  upper  margin  of  the  growth  and  divided,  the  sur- 
rounding woimd  being  at  this  stage  carefully  packed  witli  gauze  in 
order  to  prevent  contamination  if  any  fgecal  matter  should  escape. 
The  meso-rectum  and  pre-sacral  cellular  tissue  is  now  divided  at  the 
same  level,  vessels  being  clamped  as  they  are  cut.  As  soon  as  the 
growth  is  removed  the  upper  stump  must  be  wrapped  up  in  a  piece 
of  iodoform  gauze  while  the  wound  is  attended  to.  All  bleeding 
must  be  arrested,  vessels  ligatured,  and  the  wound  wiped  over  with 
pledgets  of  gauze  ^^'rung  out  of  hot  percldoride  or  formalin  lotion 
(l  in  2000). 

Treatment  of  the  Peritonseal  "Wound. — If  the  opening  into  the 
peritonaeum  be  quite  a  small  one  this  may  be  ligatured  or  sutured,  liut 
should  a  large  aperture  be  present  Kraske  advises  that  it  be  simply 
plugged  with  a  tampon  of  iodoform  gauze  and  nO  attempt  at  suture 
made,  since  plugging  is  undoubtedl}^  safer,  whilst  suturing  may  be 
attended  with  much  difficulty  and  occupy  considerable  time. 

Treatment  of  the  Ends  of  the  Bowel. — The  metliods  advocated  by 
different  surgeons  as  regards  this  most  important  step  vary  very  con- 
siderabl}^  and  at  the  present  time  it  cannot  be  said  that  the  question 
is  by  any  means  settled.  Kraske  (loc.  cit..  p.  499)  after  having  aban- 
doned it  for  some  time,  on  account  of  repeated  failures,  has  finally 
returned  to  his  original  plan  of  immediate  direct  suture,  finding  that 
complete  or  almost  complete  imion  can  be  obtained  if  the  bowels  are 
kept  constipated  for  eight  to  ten  da3^s  after  the  operation.    The  anterior 


512 


OPERATIONS  OX  THE  ABDOMEN. 


Fig.  200. 


and  lateral  portions  are  united  by  two  tiers  of  sutures,  one  passing 
through  the  whole  thickness  of  the  bowel,  and  the  other  through 
mucous  membrane  only.  The  posterior  part  is  closed  b}'  inverting 
sutures  not  involving  the  mucous  surface.  Where  the  groA^iih  does 
not  reach  very  low  down  this  method  may  be  carried  out,  but  if  the 
external  sphincter  has  to  be  sacrificed,  a  sacral  anus  ma}'  be  formed  by 
fixino-  the  upper  divided  end  of  the  bowel  to  the  posterior  angle  of  the 
wound  as  recommended  by  Hochenegg  (Brit.  Med.  Journ.,  vol.  i.  1900, 
p.  1 031).  Paul,  who  gives  a  series  of  twenty-eight  cases  with  four 
deaths  (Lancet,  vol.  ii.  1897,  p.  78),  has  abandoned  approximation  of 
the  divided  ends  if  more  than  three  inches  of  the  rectum  have  been 
removed,  and  uses  one  of  his  tubes  (Fig.  39)  in  the  following  manner, 
as  descri1:)ed  in  a  former  paper. 

The  rectum  is  first  thoroughly  freed  by  opening  the  peritonteal  sac, 
and  dividing  as  much  of  the  meso-rectum  as  is  necessary.  "  When 
plenty  of  the  bowel  has  been  drawn  down,  the  rent  in  the  peritonaeum 
niav  be  looseh"  closed  with  a  few  fine  sutures,  and  a  large  glass  intestinal 
drainage  tube,  plugged  with  wool,  is  inserted  into  the  bowel  and  liga- 
tured above  the  growths.  If  the 
intestine  is  loaded  with  fasces  the 
tube  had  better  be  introduced 
below  the  stricture  and  forced  up,* 
to  the  detriment  of  the  specimen, 
as  it  is  very  difficult  to  avoid  some 
escape  of  faeces  when  this  powerful 
bowel  is  opened  under  high  press- 
ure. The  tube  having  been  fas- 
tened in.  the  diseased  part  is  cut 
off  and  the  stump  sutured  to  the 
top  corner  of  the  wound ;  the 
higher  the  better,  as  less  gut  needs 
to  be  drawn  and  the  orifice  is 
in  a  more  favourable  position  for 
the  truss  t  (Brit.  Med.  Journ.,  1895,  vol.  i.  p.  520)."  This  method  of 
inserting  a  tube  has  the  advantages  of  being  simple  and  rapidly  used ; 
it  also  prevents  contamination  of  the  wound  with  fgeces,  and  further,  any 
large  vessels  in  the  intestinal  wall  are  closed  Avith  a  single  ligatui'e. 
The  tube  becomes  loose  about  the  fourth  day.  The  disadvantage  of  the 
tube  is  that  its  presence  prevents  the  surgeon  from  fashioning  a 
smaller  artificial  anus.  But  this  is  a  minor  point.  However  well  the 
anus  may  look  at  the  time,  artificial  support  is  almost  certain  to  be 
required  later  on,  when  part  of  the  sacrum  and  coccyx  has  been  removed. 
Hence,  to  prevent  prolapsus,  and  to  aid  in  giving  a  patient  control,  such 
a  truss-pad  as  that  of  Mr.  Paul's  will  be  found  a  real  boon  (vide  Fig.  200). 
Gersuny  (Centr.  f.  Cliir.,  1893,  ^o-  6)  advocates  treating  the  upper 
end  of  the  rectum,  if  long  enough,  by  torsion,  and  then  fixation  of  the 

*  This  would  appear  to  me  to  run  some  risk  of  carrying  up  cancer  cells  on  the  upper 
edge  of  the  glass  tube,  and  perhaps  infecting  the  cut  edge  of  the  bowel  above,  when 
the  gut  is  severed  very  shortly  after. 

t  I.e.,  The  rectal  pad  carried  by  the  truss  will  be  more  out  of  the  way,  especially 
when  the  patient  is  sitting  down.  Mr.  Paul's  truss  is  figured  in  the  above-mentioned 
paper. 


Paul's  truss  for  use  alter  excision 
of  the  rectum. 


EXCISIOX  OF  TPIE  RECTUM.  513 

twisted  gut  to  the  skin  by  suture.  The  end  is  grasped  by  catch-forceps 
and  twisted  around  its  own  long  axis  until  considerable  resistance  is 
experienced  on  attempting  to  introduce  the  finger  into  the  bowel.  He 
has  treated  two  cases  in  this  way  successfully.  Mr.  Ball  (loc.  supra  cit.) 
has  also  used  it  in  one  case,  and  recommends  it.  Dr.  Gerster,  of  New 
York,  has  published  two  cases  in  which  he  adopted  this  plan  success- 
fully, and  thinks  that  the  method  deserves  preference  and  extensive 
trial  (Med.  Record,  Feb.  10,  1894;   Ann.  of  Surg.,  Oct.  1895,  P-  499)- 

Witzel*  reports  (Centr.  f.  Cliir.,  1894,  No.  40)  six  successful  cases  in 
which  the  end  of  the  rectum  was  treated  as  follows.  A  short  incision 
having  been  made  a  little  above  the  free  margin  of  the  glutaeus  maximus, 
this  muscle  is  perforated  with  a  blunt  instrument,  and  the  rectal  stump 
drawn  through,  the  edges  of  the  gut  being  united  to  those  of  the  skin. 

Murphy's  button  has  also  been  used  to  unite  the  ends  of  the  bowel,  a 
successful  case  being  described  by  Taylor  (loc.  supra  cit.)  in  which  "  the 
button  A\'as  removed  on  the  tenth  day  by  gentle  traction  through  the 
anus  and  the  bowels  were  made  to  act.  Some  faeces,  however,  came  by 
the  wound."  The  fistula  rapidly  contracted  and  was  completely  closed 
about  six  weeks  after  the  operation. 

Taylor  also  describes  a  successful  case  treated  by  the  method  of 
Moulonguet  of  Amiens.  "  He  removes  the  mucous  membrane  of  the 
lower  segment  down  to  the  anus,  taking  good  care  not  to  injure  the 
external  sphincter.  When  the  cancer  has  been  excised  he  draws  down 
the  upper  end  and  sutures  it  to  the  sj^hincteric  orifice.  Moulonguet 
remarks  that  with  this  method  there  is  less  chance  of  abscess  and 
fistula,  since  the  intestine  opens  on  to  the  exterior." 

Keen  (Journ.  Amer.  Med.  Assoc,  1898)  is  in  favour  of  total  closure  of 
the  lower  end  and  establishing  a  permanent  abdominal  anus.  He  per- 
forms a  preliminary  inguinal  colotomy,  and  about  a  fortnight  later 
removes  the  rectum  by  Kraske's  method.  The  lower  end  of  the  bowel 
is,  however,  closed  entirely  by  means  of  sutures.  The  advantages 
claimed  are  that  neither  faeces  nor  mucus  escape  into  the  wound,  so  that 
primary  union  may  be  obtained ;  that,  since  there  is  no  escape  of  fasces 
or  mucus  after  recovery,  the  patient  need  not  wear  a  napkin ;  and,  thirdly, 
that  prolapse  is  avoided. 

The  question  of  the  treatment  of  the  end  of  the  rectum  having  been 
decided,  the  gut  placed  in  the  position  which  it  is  to  occupy, 
and  a  source  of  contamination  thus  removed,  the  wound  must  be 
attended  to.  The  deep  recesses  of  the  wound  are  then  most  thoroughly 
cleansed  by  irrigation  with  lot.  hydr.  perch,  (i  in  4000),  iodoform  or 
glutei,  carefully  dusted  in,  and  the  chief  cavities  of  the  wound  filled 
with  drains  of  iodoform  gauze.  Oozing  must  be  checked  by  irrigation 
with  hot  fluids,  leaving  on  Spencer  Wells's  forceps,  or  plugging. 
Drainage-tubes  must  be  inserted  at  points  where  there  is  obstinate 
oozing,  or  pockets  difficult  of  thorough  cleansing. f 

*  Willems  and  Rydygicr  had  recommended  a  similar  step  before,  from  experiments 
on  the  dead  body  QC'etitr.  f.  Chir.,  1893,  No.  19 ;  1894,  ^o.  45). 

f  I  have  no  space  to  allude  to  the  many  modifications  of  Kraske's  operation  :  para- 
sacral, osteo-plastic,  and  others.  As  in  many  other  operations,  these  modifications  do 
not  appear  to  me  to  be  improvements.  Moi-eover,  most  of  them,  owing  to  their 
additional  severity,  are  quite  uusuited  to  the  patients  who  come  to  us  with  rectal 
cancer.  Many  of  them  are  mentioned  in  a  helpful  article  by  Dr.  A,  G.  Gerster  (^Ann. 
of  S^irg.,  Oct.  1895,  P-  485). 

VOL.    II.  II 


514 


OPERATIONS  ON  THE  ABDOMEN. 


The  Management  of  Defsecation. — Here  there  is  a  divergence  of 
opinion.  The  majority  of  surgeons  have  endeavoured  to  retard  as  long- 
as  possible  the  first  action  of  the  bowels.  This — the  bowel  not  acting 
till  the  sixth  or  eighth  day — is  facilitated  by  previously  emptying  them 
thoroughly  (p.  501).  Others  have  held  that  if  the  bowel  can  be 
brought  down  satisfactorily  under  the  cut  sacrum  or  into  the 
perinaeum,  and  the  recesses  of  the  wound  kept  plugged,  an  early  action 
of  the  bowels  will  be  safe.  Much  must  depend  on  the  state  of  the 
patient  as  to  flatulent  distension,  a  condition  which  is  very  variable  in 
different  individuals. 

(iii)  Excision  of  the  Rectum  by  the  Vagina. — This  method  was 
introduced  by  Campenon  {France  Medicale,  1894)  and  Rehn  (Centr.  f. 
Ghir.,  1895,  No.  10).  The  rectum  and  vagina  having  been  disinfected, 
the  posterior  vaginal  wall  is  divided  vertically  along  the  middle  line, 
together  with  the  rectum,  the  incision  being  carried  through  the 
perinseum  to  the  anterior  margin  of  the  anus,  w^here  it  stops  or  bifur- 


Mayo  Robsoii's  decalcified  boue  bobbins  (p.  241),  latest  pattern.     Largest  size 
for  operation  on  the  large  intestine.     (Down's  Catalogue.) 


cates,  according  as  the  anus  is  to  be  removed  or  not.  The  bowel  is 
separated  from  the  vagina  by  careful  dissection,  and  having  been  freed 
behind,  is  divided  above  the  disease  between  two  ligatures  applied  as  a 
protection  against  faecal  infection.  The  upper  part  is  drawn  out  of  the 
way  by  an  assistant  towards  the  symphysis,  any  tissues  holding  it  down 
being  thus  put  on  the  stretch  and  easily  divided.  The  surgeon  then 
taking  the  diseased  segment  deals  with  it  either  by  entire  removal,  or 
resection,  if  the  anal  orifice  can  be  spared.  If  the  peritoneeum  is  not 
opened,  the  growth  is  cut  away,  and  the  bowel  drawn  down  and  sutured. 
If,  however,  the  peritonaeum  must  be  opened,  this  is  easily  done,  any 
glands  in  the  meso-rectum  removed,  and  the  highest  part  of  the  rectum 
drawn  down.  The  precautions  already  given  as  to  the  treatment  of  the 
meso-rectum  and  its  vessels  (p.  511)  must  be  remembered  here.  The 
peritonaeal  opening  is,  later,  to  be  sutured.  The  upper  end  of  the  gut 
is  sutured  to  that  left  just  above  the  anus  if  possible,  the  perinaeal  and 
vaginal  wounds  are  also  sutured,  drainage  being  provided  by  two  tubes 
placed  on  either  side  of  the  rectum,  and  brought  out  in  the  ischio-rectal 


EXCISION  OF  THE  I!ECTOI.  515 

fossoe.  Rehn's  case,  an  aged  woman  of  81,  died  of  septic  peritonitis  on 
the  third  day.     Campenon  reports  a  recover}'. 

(iv)  Excision  of  Rectum  by  Laparotomy. — This  mode  of  attacking 
rectal  cancer  is  justifiable  where  the  growth  is  situated  very  high  up,  at 
the  junction  of  the  rectum  and  sigmoid  flexure,  too  high  for  the  employ- 
ment of  the  sacral  route,  and  too  low  to  be  reached  by  the  far  safer 
resection  from  the  left  iliac  fossa  (p.  259). 

The  bowels  having  been  most  thoroughly  emptied,  the  bladder  is 
emptied  by  a  catheter,  and  the  abdomen  opened  by  an  incision  in  the 
middle  line,  brought  as  low  down  as  possible.  The  small  intestines  are 
then  packed  out  of  the  way,  and  the  growth,  if  possible,  brought  well 
up  into  view.  Trendelenberg's  position  (p.  387)  may  facilitate  this.  If 
adhesions  interfere  with  safe  manipulation  of  the  growth,  the  operation 
should  be  abandoned.  If  it  is  possible  to  proceed,  the  following  steps 
are  open  to  the  surgeon :  (A)  To  resect  the  growth,  and  to  unite  the 
ends  with  a  large-sized  Robson's  bobbin  (p.  514,  Fig.  201)  or  Murphy's 
button  (p.  236).  If  the  bowels  are  empty,  and  if  the  patient's  con- 
dition calls  for  speed}^  operating,  this  position  is  one  most  favourable 
to  the  button.  Every  possible  care  must  be  taken  with  clamps  and  the 
assiduous  use  of  gauze  sponges  to  secure  that  no  infection  of  the  wound 
takes  place.  Another  method,  Maunsell's  (p.  233),  which  lias  been  suc- 
cessfully used  for  the  removal  of  an  intussusception  (Hartley,  Xeiv  YorJc 
Med.  Joiii'ii.,  Oct.  22,  1892)  is  also  applicable  to  carcinomata. 

(B)  Paul  suggests  (loc.  sajrra  cit.)  tliat  in  cases  where  the  bowels  are 
not  emptied  the  safer  plan  would  be  "to  double  ligature,  and  divide 
the  bowel  above  the  growth,  taking  the  upper  end  out  through  a  small 
separate  wound  in  the  inguinal  region,  where  subsecjuently  a  tube  could 
be  inserted  and  an  artificial  anus  established.  Then  excise  the  diseased 
portion  of  the  rectum,  and  invaginate  and  close  the  lower  end." 

(v)  Excision  of  the  Rectum  by  the  Abdomino-perinseal  Method. — 
This  plan,  which  is  advocated  by  M.  Quenu.  of  Paris,  is  thus  described 
by  Allingham  (Med.  Ann.,  1901,  p.  464):  "A  preliminary  sigmoidos- 
tomy  is  carried  out  some  days  beforehand.  The  belly  is  opened  in  the 
middle  line,  and  both  internal  iliac  arteries  are  ligatured.  The  already 
existing  sigmoid  anus  is  liberated,  and  the  bowel  is  completely  cut 
across  with  the  thermo-cautery.  The  cut  ends  are  cleansed  and 
enveloped  in  iodoform  gaiize.  The  upper  end  is  then  brought  out  in 
the  left  iliac  region,  and  constitutes  the  permanent  anus.  The  lower 
end  is  freed  by  dividing  the  meso-sigmoid  and  meso-rectum  along  the 
entire  length  of  the  hollow  of  the  sacrum.  It  is  then  packed  with  gauze 
at  the  lower  part  of  the  pelvis.  The  abdominal  wound  is  closed.  The 
patient  is  then  placed  in  the  lithotomy  position,  and  the  final  steps  of 
the  operation  are  carried  out  from  the  pei'injBum.  After  plugging  the 
anal  canal,  semilunar  incisions  are  made  on  either  side  of  the  anus,  the 
levatores  ani  are  divided,  the  anterior  wall  of  the  rectum  is  carefully 
liberated,  the  pouch  of  Douglas  is  opened,  the  remaining  connections 
are  divided,  and  the  diseased  segment  of  bowel  (along  with  the  gauze 
stufiing  in  the  pelvis)  is  brought  out  of  the  wound  and  removed.  In 
two  cases  in  which  the  author  carried  out  the  above  operation  success- 
fully '  there  was  not  the  slightest  shock  " — a  fact  which  was  corroborated 
by  M,  Nelaton,  who  was  present." 

Such  a  severe  operation  as  the  above  can,  howeve'',  be  very  rarely 


5l6  OPERATIONS  ON  THE  ABDOMEN. 

needed,  and,  moreover,  patients  suffering  from  rectal  cancer  would 
only  ver}"  exceptionally  be  in  a  condition  to  undergo  such  an  operation 
with  any  chance  of  a  successful  issue. 

After-treatment. — The  chief  points  here  are  to  keep  the  wound  sweet 
by  frequent  syringing  with  dilute  mercury  perchloride  solutions,  the 
careful  insufflation  of  iodoform,  and  the  keeping  all  pockets  dry.  The 
catheter  will  probably  be  required,  and  a  mild  aperient  may  be  given 
about  the  sixth  day,  if  needed.  The  finger  should  be  occasionally 
passed  with  the  utmost  gentleness,  and  after  a  week  or  ten  days,  a 
bougie,  or  vulcanite  tube  fp.   50  0- 

Question  of  Golotomy  before  Excision  of  the  Rectum. — Theoretically, 
this  preliminary  step  would  seem  very  advisable,  as  diverting  the 
fEeces,  and  thus  a  source  of  decomposition,  and  as  doing  away  with 
the  need  of  the  use  of  bougies  to  prevent  contraction  (Haslam, 
St.  Thomas's  Hosp.  Bep.,  vol.  xviii.  p.  151).  From  a  practical  point  of 
view,  I  do  not  think  a  preliminary  colotomy  advisable,  save  in  an  early 
case  (where  time  has  not  slipped  away),  and  in  one  where  the  disease 
extends  high  up.  It  wastes  precious  time,  and  entails  two  operations 
in  patients  too  often  with  poor  vitality  and  too  little  power  of  repair. 
Moreover,  the  results  of  excision  of  the  rectum,  especially  those  of 
Mr.  Cripps  and  Mr.  Allingham,  show  that  this  preliminary  is  not 
needed.  Finally,  as  remarked  by  Mr.  Ball,  the  advantages  of  retaining 
a  fgecal  outlet  in  the  perinseum  are  great,  so  long,  of  course,  as  this  is 
not  contracted. 

Causes  of  Trouble  and  Failure  after  Excision  of  the  Rectum. — 

I.  Shock.  2.  Hcemorrhage.  This  will  rarely  be  difficult  to  deal  with 
at  the  time,  or  met  with  later,  if  the  surgeon  has  plenty  of  Spencer 
Wells's  forceps,  good  assistants,  and,  if  he  does  the  operation  steadily, 
controlling  each  vessel  as  met  with.*  This,  aided  by  hot  injections 
(p.  513)  and  firm  sponge  pressure,  will  usually  prevent  any  secondary 
haemorrhage.  If  this  should  occur.  Prof.  Macleod's  advice  should  be 
followed — viz.,  to  pass  a  large  tube  into  the  bowel  for  the  escape  of 
flatus,  tScc,  and  to  pack  carbolised  sponges,  or  strips  of  gauze,  firmly 
round  this.  3.  Suppuration.  Cellulitis  and  other  septic  troubles 
4.  Peritonitis.     5.  Exhaustion.     6.  Recurrence. 

After  the  high  removal  the  above  will  be  present  in  intensified  form. 
In  addition  the  following  must  be  remembered  :  7.  Gangrene  of  the 
stump  of  the  bowel  from  over-interference  wdth  its  blood-supplj^  or 
retraction  of  the  superior  hasmorrhoidal  artery  (Morestin,  quoted  by 
A.  G.  Gerster,  loc.  supra  cit.,  Gaz.  des  Hop.,  1894,  p.  326).  8.  Sacral 
fistula.  This  ma}^  be  prim,arij  from  defective  sutures  of  the  bowel,  or 
secondary  from  the  formation  of  {9)  a  stricture  after  resection. f  10.  If 
the  fistula  does  not  close  it  must  be  submitted  to  a  plastic  operation. 

I I .  Prolapsus.     This  may  date  to  the  operation,  or  to  straining  after- 


*  Mr.  Cripps  has  shown  that,  as  most  of  the  bleeding  comes  from  vessels  situated  in 
the  walls  of  the  rectum,  dragging  down  the  bowel  with  a  firm  grasp  will  not  only 
greatly  facilitate  the  operation,  but  also  prevent  haemorrhage. 

t  A.  G.  Gerster  (loc.  supra  cit.  i  holds  that  resection  has  been  invariably  followed  by 
a  stricture,  no  matter  what  form  of  approximation — suture,  Murphy's  button,  or 
invagination — is  used.  Frequent  digital  examination  is  indispensable;  the  stricture, 
if  detected  early,  will  yield  to  systematic  dilatation  with  a  bougie. 


IMPERFORATE  AXUS  AND  RECTUM. 


517 


Avards  and  yielding  or  bursting  of  the  scar.     This  tendency  will  be  met 
by  the  use  of  Mr.  Paul's  truss  or  one  like  it  (p.  512). 


IMPERFORATE  ANUS.  —  ATRESIA  ANI.  —  IMPERFECTLY 
DEVELOPED  RECTUM  (Figs.  202-208). 

A  surgeon,  when  called  upon  to  explore  these  cases,  will  do  well  to 
bear  in  mind  the  following  natural  and  practical  classification,  because 
on  this  depends  his  treatment : — 

Two  Main  Varieties  :  A.  Cases  in  which  no  normal  anus  exists — 
Imperforate  Anus.  B.  Cases  in  which  a  normal  anus  exists,  but  the 
gut  is  obstructed  higher  up,  or  undeveloped — Imperforate  Rectum. 

A.  Imjjerforate  Anus.  i.  Anus  partially  closed — («)  by  adhesions  of 
epithelial  surfaces,  as  occasionall}'  happens  in  the  labia  of  a  female 
infant ;  (/>)  by  a  membrane.  2,  Anus  completely  closed,  but  only  by  a 
membrane.     3.  Anus  completely  closed  by  a  membrane,  but  a  fistula 


Fig.  202.* 


Fig.  203. 


Anus  absent.  Eectum  opening 
by  fistula,  close  to  urethra.  (Rush- 
ton  Parker.) 


Anus  absent.  Eectam  communi- 
cating with  vagina.  (Rushton  Par- 
ker.) 


exists — (a)  on  the  surface  of  the  body  {e.g.,  the  raphe  of  the  scrotum) ; 
(b)  into  the  vagina  (Fig.  203) ;  (c)  into  the  urethra  or  bladder  (Figs. 
204,  208).     4.  Anus  imperforate  and  the  rectum  deficient  as  well. 

B.  Anus  in  natural  iwsition,  but  the  Rectum  is  deficientf — {a)  the 
rectum  is  deficient  for  a  short  distance  only,  and  separated  from  the 
anus  by  a  cul-de-sac  (Fig.  206) ;  (/')  the  rectum  is  deficient  for  a 
long  distance,  or  entirely  (Fig.  207). 

Treatment. — A.  Those  in  which  no  natural  anus  exists. 

I  and  2.  If  the  atresia  be  due  to  epithelial  adhesions,  or  to  a  more 
or  less  complete  membrane,  the  former  should  be  broken  down  and  the 
latter  snipped  away  with  scissors,  and  the  opening  kept  patent  by  a  small 
piece  of  oiled  lint,  the  nurse's  little  finger  being  introduced  twice  daily. 

3.  If  the  anus  be  imperforate,  and  a  fistula  open  {a)  on  the  surface 
of  the  body,  (6)  into  the  vagina,  or  (c)  urethra  : 

*  This,  and  the  next  six  figures,  are  taken  (with  a  few  alterations)  from  an  article 
by  Mr.  Rushton  Parker  {Liverpool  Med,  Chron..  July  1S83). 

t  As  Mr.  Holmes  has  shown,  these  cases  are  important,  as  they  are  liable  to  be 
overlooked  till  considerable  distension  has  taken  place. 


5i8 


OPEEATIOXS  OX  THE  ABDOMEN. 


Fig.  204. 


(a)  A  probe  is  passed  from  the  skin-fistula  (e.f/.,  in  the  scrotum) 
towards  the  proper  anal  site  ;  it  is  then  cut  down  upon  and  the 
opening  established  in  the  proper  position. 

(h)  If  the  j&stula  open  into  the  vagina,  the  treatment  will  vary  some- 
"\^-hat  with  the  urgency  of  the  case,  the  size  of  the  opening,  and  the  age 
of  the  child. 

Thus,  if  the  opening  be  very  small  and  the  retention  urgent,  a  silver 
director  should  be  passed  through  the  vaginal 
fistula  back  to  the  proper  site  of  the  anus, 
and  there  cut  down  upon.  If  the  bowel  is 
within  reach,  it  should  be  drawn  down  and 
stitched  in  sifit.  The  orifice  should  be  kept 
patent. 

In  such  a  case,  though  an  anus  is  established 
in  the  proper  position,  it  is  very  doubtful  if  the 
vaginal  fistula  will  close,  and  a  further  operation 
will  probably  be  required  later  on.  Plastic 
operations  should  not  be  tried  too  early  on 
account  of  the  softness  of  the  tissues  and  the 
liquid  condition  of  the  f^ces. 

If,  owing  to  the  size  of  the  vaginal  fistula. 
there  is  not  much  retention,  and  especially  if 
the  child  be  not  ver}-  young,  the  following 
operation  may  be  performed  after  the  method 
of  Rizzoli  (cjuoted  by  Mr.  Holmes,  Syst. 
of  Sun/.,  vol.  iii.  p.  788) :  An  incision  is  made  from  the  vulva  to 
the  cocc^t:  in  the  middle  line,  the  rectum  found  by  most  careful  dis- 
section, separated  from  the  vagina,  and  then  brought  down  and  fixed 


Anus  endingin  a,  cul-de-sac. 
Rectum  opening  into  urethra 
far  back.  A  case  for  Littre's 
operation.  (Rush ton  Parker.) 


Fig.  205. 


Fig.  206. 


Anus    aliseut.       Rectum    could    he 
reached      by    dissection.  (Rushtou 

Parker.) 


Anus  ending  in  cul-de-sac.  Rectum 
readily  reached  from  this.  (Rushtou 
Parker. 


in  its  natural  position.  To  aid  in  finding  the  rectum,  a  probe  should 
be  passed  from  the  fistula. 

After  the  rectum  has  been  brought  down  and  secured,  the  incision 
between  the  anus  and  vulva  is  united  to  form  a  new  perinasum. 

(c)  Fistula  into  the  urethra  or  bladder.  Two  questions  here  arise, 
How  high  tip  is  the  communication  ?  How  much  of  the  bowel  is 
deficient  ? 


IMPERFORATE  ANUS  AND  RECTUM. 


19 


If  the  perineeum  seems  fairly  developed,  if  the  ischial  tuberosities  are 
not  in  close  contact,  if  any  bulging  can  be  detected  at  the  natural  site 
of  the  anus,  the  communication  is  probably  recto-urethral,  and  an 
attempt  may  reasonably  be  made  to  find  the  bowel  from  the  perin^eum. 
If  it  is  found,  and  can  be  brought  down,  an  attempt  ma}^  be  made 
to  separate  it  from  the  adjacent  urethra,  but  usually  the  surgeon  will 
have  to  be  satisfied  with  a  free  opening,  and  with  keeping  this  patent,  so 
as  to  encourage  the  urethral  communication  to  close.  If  there  appear 
no  probability  of  the  bowel  being  within  reach,  or  if  this  cannot  be  found, 
Littre's  operation  should  be  performed  {ip.  103).  If  the  child  survive,  the 
bladder  must  be  kept  carefully  washed  out  if  anj'  faeces  still  find  their 
way  into  it.  Thus,  in  a  case  of  Mr.  Glutton's  (#S'^.  Thomas's  Hosp.  Rep., 
vol.  xi.  p.  84),  a  child  about  a  month  old  died,  sixteen  days  after  Littre's 
operation,  of  suppurating  kidneys,  due  to  the  ofiensive  purulent  urine. 

4.  Anus  absent  and  rectum  deficient  as  well.  Here  the  chief  question 
is  how  far  upwards  an  exploratory  operation  may  be  safely  conducted. 

External  evidence.  Genitals  far  back  and  close  to  the  coccyx,  and 
ischial  tuberosities  close  together,  point  to  absence  of  the  rectum. 


Fui.  207. 


Fig.  208. 


Anus  absent.  Rectum  ending  high 
up.  A  case  for  Littre's  operation. 
(Euslitou  Parker.) 


Anus  and  rectum  deficient,  the  bowel 
ending  in  the  bladder.  (Rushton  Par- 
ker.) 


In  most  cases  the  surgeon  begins  by  exploring.  The  child  being 
under  the  A.C.E.  mixture  and  in  lithotomy  position,  and  a  small  sand- 
bag placed  under  the  sacrum,  and  the  bladder  emptied  with  a  catheter, 
the  surgeon,  seated  at  a  comfortable  level,  makes  a  free  incision  from 
the  position  of  the  anus  back  to  the  coccyx.  Keeping  exactly  in  the 
middle  line,  and  opening  up  the  cellular  tissue  with  his  finger-tip,  aided 
by  a  scalpel  and  director,  the  surgeon  works  backwards  towards  the 
concavity  of  the  sacrum,  constantly  taking  note  with  his  finger-tip 
of  the  depth  to  which  he  has  got,  while  an  assistant  aids  in  bringing 
down  the  bowel  by  supra-pubic  pressure. 

As  a  rule,  two  inches  are  a  sufficient  depth  in  a  new-born  child.  If 
still  i)i  doubt  whether  to  proceed  or  no,  the  surgeon  may  make  a  careful 
])uncture  with  a  morphia-syringe  backwards,  and  note  the  condition  of 
the  point ;  no  puncture  with  a  trocar  is  justifiable  at  this  depth. 

Points  to  hear  in  mind. —  i.  The  rectum  may  end  at  the  brim  of  the 
pelvis.     2.  If  it  end  lower  down,  it  maj'  be  floating  with  a  long  meso- 


520  OPEKATIONS  ON  THE  ABDOMEN. 

rectum.  3.  Though  the  rectum  may  end  within  reach,  the  peritonaeum 
may,  and  not  infrequently  does,  extend  low  down  on  the  bowel.  4.  Even 
if  the  rectum  is  successfully  opened  high  up,  without  opening  the  peri- 
tonaeum, fatal  cellulitis  may  be  set  wp  by  the  escaping  freces,  or  by  the 
attempts  to  keep  the  bowel  patent. 

If  the  above  exploratory  operation  fail,  inguinal  colotomy  or  Littre's 
operation  should  be  resorted  to  (p.  103). 

B.  Imperforate  Rectum. — The  treatment  here  will  be  an  exploratory 
operation,  followed,  in  case  of  failure,  by  Littre's  operation  (p.  103). 


CHAPTER   XV. 

RUPTURED     PERINJEUM    (Figs.  209.  2io). 

The  following  account  is  taken  from  my  colleague,  Dr.  Galabin :  * 

A.  Operation  for  Partial  Rupture  (Fig.  209). — The  patient  is  placed 
in  lithotomy  position.  The  need  for  assistants  to  support  the  thighs  is 
avoided  if  a  "  Clovers  crutch"  is  used. 

"  The  extent  of  surface  to  be  freshened  is  indicated,  to  some  extent, 
by  the  cicatrix  left  by  the  rupture.  It  is  well,  however,  to  go  a  little 
beyond  the  limits  of  this  in  all  directions,  especially  up  the  median  line 
of  the  vagina  and  towards  the  lower  halves  of  the  labia  majora,  both  in 
order  to  secure,  if  possible,  a  perinseal  body  somewhat  larger  and  deeper 
than  the  original  one,  and  to  allow'  some  margin,  in  case  the  surfaces  do 
not  unite  completely  up  to  the  edges.  To  put  the  mucous  membrane  on 
a  stretch,  an  assistant  at  each  side  places  one  or  two  fingers  on  the  skin 
of  the  thigh  and  draws  the  vulva  outwards  (Fig.  209).  The  skin  just 
beneath  a,  in  front  of  the  anus,  may  also  be  seized  by  a  tenaculum  and 
drawn  downwards.  If  still  the  mucous  membrane  is  not  sufficiently  on 
the  stretch,  from  laxit}^  of  the  vagina,  the  posterior  vaginal  wall,  some 
distance  above  b,  should  be  seized  by  long-handled  tenaculum-forceps 
and  pushed  upwards.  Incisions  are  then  made  through  the  mucous 
membrane  from  b  to  a,  in  the  median  line  of  the  vagina,  and  from  a  to 
c  and  D  through  the  junction  of  mucous  membrane  and  skin.  These 
should  not  be  extended  in  the  direction  of  C  and  D  farther  than  the 
lower  extremity  of  the  nymphee  at  the  utmost.  There  are  then  two 
triangular  flaps,  ABC  and  abd.  These  are  to  be  dissected  up  from  the 
apex  a  towards  the  base  BC  and  bd,  the  corner  of  the  mucous  membrane 
at  A  being  seized  with  dissecting  forceps.  The  dissection  should  not  be 
deeper  than  necessary,  and  if  it  is  done  with  the  knife  the  surfaces  are 
more  ready  to  unite.  If,  however,  there  is  much  tendency  to  bleed, 
scissors  may  be  used.  1'he  apices  of  the  flaps  are  then  cut  off"  with 
scissors,  leaving  an  upturned  border  along  bc  and  bd.  When  the  sur- 
faces are  drawn  together  these  borders  form  a  slightly  elevated  ridge 
towards  the  vagina,  and  if  there  is  any  failure  of  vmion  jiist  along  the 
edge  they  fall  over  and  cover  it. 

"  The  best  material  for  sutures  is  the  silkworm-  or  fishing-gut,  which 
should  be  stout,   of  the  thiclcness  used  for  salmon  flies.     It  may  be 

*  Diseases  of  Women,  pp.  130,  381.      Anyone  making  trial  of  this  method  will  agree 

with  me  as  to  its  simplicity  and  excidliMit  results. 


522 


OPERATIONS  OX  THE  ABDOMEN. 


stained  with  magenta,  to  render  it  more  easil}"  visible.  This  has  all  the 
advantage  of  silver  wire,  as  being  non-absorbent,  while,  at  the  same 
time,  it  is  easier  to  manipulate,  and  the  exposed  ends  do  not  cause 
discomfort  after  the  operation,  like  those  of  wire.  The  sutures  are 
placed  as  shown  in  the  figure.  The  most  convenient  needle  is  a  slightly 
curved  one.  not  too  thick,  mounted  in  a  handle.  This  is  passed  in,  un- 
threaded, rather  close  to  the  edge  of  skin,  brought  out  on  the  raw 
surface,  then  tlu'eaded  with  the  end  of  the  suture,  which  is  so  drawn 
through.  By  passing  the  needle  in  the  same  way  on  the  other  side,  the 
other  end  of  the  suture  is  drawn  through.  Another  mode  is  to  use  a 
more  curved  needle,  and  to  bury  the  sutures,  1,2.  and  3,  in  the  tissues 
throughout  their  whole  course.    If,  however,  they  are  brought  out  in  the 

Fig.  209. 


(Galabiu.) 

centre  for  spaces  alternately  short  and  long  (Fig.  209),  the  surfaces  are 
more  easily  brought  into  contact  at  all  levels  without  undue  tension. 
In  passing  sutures  4.  5.  6  the  needle  should  be  brought  out  precisely  on 
the  margin  along  which  the  border  of  mucous  membrane  BC,  bd  is 
turned  up  from  the  vagina,  not  passing  through  the  mucous  membrane 
itself.  The  sutures  are  then  tied  in  the  order  of  the  numbers  i  to  6, 
care  being  taken  that  the  surfaces  are  brought  just  sufficiently  into 
apposition,  and  that  no  clots  or  blood  are  left  between  them.  The  bleed- 
ing, if  any  continues,  is  arrested  by  bringing  the  surfaces  together,  and 
if  they  are  properly  united  there  will  be  no  secondary  haemorrhage, 
unless  the  sutures  begin  to  cut  from  excessive  tension.  The  sutures 
may  be  left  in  from  seven  to  ten  daj'S." 


EUl^TUEED  PERINEUM. 


523 


Operation  for  Complete  Rupture  (Fig.  210). — The  preliminary  steps 
are  taken  as  above.  "  A  point  15  in  the  median  line  of  the  vagina,  a 
sufficient  distance  above  the  apex  of  the  rent  in  the  septum,  is  taken,  and 
an  incision  through  the  mucous  membrane  is  made  from  b  to  G.  and 
from  G  to  E  and  v  along  the  edges  of  the  septum,  between  the  rectal 
mucous  membrane  and  the  cicatrix.  Incisions  are  also  made  through 
the  skin  from  E  to  C  and  f  to  D,  so  that  the  freshened  surface  may 
extend  somewhat  beA'ond  the  limits  of  the  cicatrix,  c  or  D  not  to  be 
higher  than  the  lower  extremities  of  the  nj-mpliEe.  The  quadrilateral 
flap,  EGBC  is  then  seized  at  E  by  dissecting  forceps,  and  dissected  up  with 


(Galabiu.) 


the  knife  from  the  angle  k.  and  afterwards  from  the  angle  G,  towards  the 
base  BC.  While  this  is  done,  the  parts  are  kept  on  the  stretch  by  an 
assistant  drawing  down  the  skin  below  E  with  a  tenaculum.  The  flaj)  is 
then  cut  away  ^\■ith  scissors,  except  an  upturned  border,  which  is  left 
along  BC.  The  flap  fgbd  is  treated  in  a  similar  manner.  If.  as  is  usual, 
the  ends  of  the  sphincter  at  E  and  f  have  retracted  from  the  margin 
of  the  cicatrix,  it  is  well  to  cut  away  with  the  scissors  a  narrow  strip  of 
rectal  mucous  membrane,  generally  somewhat  everted,  a  short  distance 
from  E  and  F  towards  g.  so  as  to  bring  the  freshened  surface  to  the  ends 
of  the  sphincter. 

•'  Sutures  of  silkworm-gut  are  then  applied  in  the  following  manner : 


524  OPERATIONS  OX  THE  ABDOMEN. 

First,  rectal  sutures,  either  two  or  three,  accoi'ding  to  the  extent  of  the 
rent  in  the  septum,  are  applied.  These  are  destined  to  be  tied  in  the 
rectum,  and  the  ends  left  projecting  through  the  anus.  They  are  best 
applied  with  a  half-curved  needle,  held  in  a  holder.  The  needle  is 
passed  in  a  little  distance  from  the  margin  of  the  rent,  and  brought  out 
almost  at  the  very  edge  of  the  rectal  mucous  membrane,  on  the  line  GF. 
The  needle  is  then  threaded  at  the  other  end  of  the  suture,  and  that  is 
drawn  through  in  the  same  way  from  without  inwards,  on  the  margin  eg. 
Next,  two  sutures  at  least  are  passed  completely  round  through  the 
remnant  of  the  septum,  by  means  of  a  curved  needle,  not  too  large, 
mounted  in  a  handle.  This  is  passed  unthreaded,  and  draws  the  suture 
back  with  it  on  withdrawal.  The  first  of  these  (3,  Fig.  210)  is  passed 
in  somewhat  behind  and  below  the  angle  F,  so  as  to  take  up,  if  possible, 
or  at  least  go  quite  close  to,  the  end  of  the  divided  sphincter,  and  is 
brought  out  in  a  similar  position  near  e.  Thus,  when  tightened,  it 
brings  together  the  ends  of  the  sphincter,  drawing  it  into  a  circle ;  but 
it  often  brings  into  apposition,  not  so  much  the  freshened  surfaces  above 
as  the  unfreshened  rectal  mucous  membrane.  This  serves  as  a  barrier 
to  keep  out  faecal  matter,  while  the  next  suture  (4,  Fig.  210)  aids  the 
rectal  sutures  in  uniting  the  freshened  surfaces.  The  remaining  sutures 
are  passed  as  shown  in  the  figure  (5 — 8,  Fig.  210)  by  a  slightly  curved 
needle  mounted  in  a  handle,  in  the  same  way  as  in  the  operation  for 
incomplete  rupture  (Fig.  210).  The  needle,  unthreaded,  is  passed  in 
prett}'  close  to  the  edge  CE  or  fd.  is  brought  out  (except  in  the  case  of 
suture  5,  Fig.  210)  on  the  line  where  the  margin  CB  or  db  is  turned  up, 
and  draws  one  end  of  the  suture  back  w^ith  it,  the  other  end  being* 
afterwards  drawn  through  in  the  same  way.  The  efiect  is,  that  w'hen 
the  sutures  are  tightened,  the  margins  bc,  bd  are  turned  up  into  a 
slight  ridge  towards  the  vagina,  and  afterwards  fall  over  and  cover  any 
portion  of  the  vaginal  border  which  does  not  unite  quite  up  to  the  edge. 
Suture  5  (Fig.  210)  may  either  be  buried  throughout,  or  brought  out 
for  a  very  short  space  near  the  median  line  bg. 

"  When  all  the  sutures  are  in  place,  the  sponge*  is  withdrawn  from  the 
rectum,  and  the  rectal  sutures  are  tied  first.  Care  must  be  taken  to- 
draw  up  the  whole  of  the  slack  in  the  centre,  and  bring  the  edges, 
EG,  fg  perfectly  together.  This  will  approximate  the  ends  of  the 
sphincter  to  a  great  extent,  and  the  approximation  is  completed  by 
tightening  suture  3.  The  remaining  sutures  are  then  tied  in  the  order 
of  the  numbers,  care  being  taken  to  allow  no  clots  or  blood  to  remain 
between,  and  to  tighten  them  just  enough  to  bring  the  surfaces  in  con- 
tact. The  ends  of  the  rectal  sutures  may  be  left  moderately  long,  to 
distinguish  them,  the  rest  cut  pretty  short. 

"  The  peringeal  sutures  are  removed  in  seven  days.  The  rectal  sutures 
may  be  left  from  ten  to  fourteen  da^^s  longer,  till  the  peringeum  is  con- 
solidated. They  are  then  removed  through  a  small  rectal  speculum, 
care  being  taken  not  to  break  down  any  of  the  imion  in  passing  it. 
B}'  this  operation  the  anus  is  generally  much  more  completely  restored 
than  by  the  use  of  quilled  sutures,  or  the  plan  of  making  deep  lateral 
incisions  to  relieve  tension.     If  there  is  miich  resistance  to  bringing  the 

*  This,  secured  with  tape,  is  introduced  into  the  bowel,  to  prevent  the  descent  of  any 
f seccs  left  by  an  enema. 


RUPTURED  PERIX.EUM.  525 

surface  together,  the  only  thing  required  is  to  use  more  numerous  sutures, 
so  as  to  diminish  the  tension  on  each. 

"  In  some  cases,  by  the  primary  operation  after  labour,  only  superficial 
union  is  secured,  and  a  recto-vaginal  fistula  is  left  close  to  the  part 
united.  The  best  plan  is  then  to  cut  through  the  bridge  of  union  with 
scissors  at  the  time  of  the  operation,  and  then  proceed  as  in  the  case  of 
complete  rupture.  This  is  the  onl}''  way  to  secure  a  firm  and  thick 
perinaeum,  and  is  less  likely  to  fail  than  an  operation  on  the  fistula 
alone." 


CHAPTER    XVI 
OPERATIONS    ON    THE    OVARY. 

OVARIOTOMY. 

One  or  two  practical  points  will  be  alluded  to  before  the  operation 
is  described. 

Date  of  Operation. — An  ovarian  tumour  should  be  removed  as  soon 
as  possible  after  its  discovery.  For,  by  delay,  not  only  is  the  patient 
subjected  to  the  risk  of  accidents  in  connection  with  the  tumour  itself, 
but  her  general  health  is  likely  to  suffer  from  the  effects  of  pressure  on 
neighbouring  organs. 

Accidents  in  connection  with  Tumour. — The  accidents  to  which 
an  ovarian  tumour  is  liable  should  be  borne  in  mind.  They  are  shortly, 
as  follows : — 

(i)  Inflammatori/  Chariges. — These,  whether  confined  to  the  perito- 
na?al  covering  or  dependent  upon  inflammatory  and  necrotic  changes 
in  the  cvst  itself,  will  lead  to  adhesions  between  the  tumour  and  the 
abdominal  wall  or  viscera.  When  recent,  these  adhesions  may  readily 
be  separated,  but  when  old  and  fibrous  they  may  lead  to  serious 
difficulties  in  the  course  of  the  operation.  The  contents  of  the  cyst 
may  suppurate,  and,  fouling  the  peritonseal  cavity,  lead  to  suppurative 
peritonitis. 

(2)  Torsion  of  the  Pedicle. — When  slowly  produced,  the  interference 
with  the  blood-supply  to  the  tumour  will  set  up  necrosis  and  so  render 
the  cyst-wall  liable  to  rupture.  Acute  torsion  A^'ill  lead  to  bleeding, 
which  may  be  so  profuse  as  to  rupture  the  cyst-wall  and  endanger  the 
patient's  life.  Under  these  circumstances  an  immediate  operation  is 
called  for,  with  all  the  disadvantages  that  an  operation  of  urgency 
entails. 

(3)  Eujohire  of  the  Cyst. — This  may,  as  has  been  mentioned,  follow 
necrotic  changes  in  the  cyst  or  torsion  of  the  pedicle.  It  may,  in 
addition,  depend  merely  upon  thinness  of  the  wall  or  upon  weakening- 
due  to  the  extension  of  growth  from  the  interior  through  the  cyst-wall. 
As  a  result  the  contents  become  disseminated  through  the  peritonaeal 
cavity,  setting  up  peritonitis  in  certain  cases,  or  leading  to  a  general 
infection  of  the  peritonaeum  with  growths  in  others. 

(4)  Malignancy. — We  have,  finally,  to  remember  this  important  prac- 
tical point,  that  it  is  difficult  at  an  early  stage  to  say  whether  we  are 


OVARIOTOMY.  527 

dealing  with  a  malignant  growth  or  not.  It  is  especially  in  cliildren 
that  an  early  removal  is  demanded,  for  in  them  the  proportion  of 
malignant  growths  is  much  higher  than  in  adults.  Mr.  Bland  Sutton 
found  twenty-one  cases  of  sarcoma  in  a  series  of  one  hundred  ovario- 
tomies performed  in  girls  under  the  age  of  15-  {Bland  Sutton, 
S'urijical  Diseases  of  the  Ovaries  ami  Fallopian  Tubes,   1896,  p.    178.) 

General  Condition  of  the  Patient. — The  condition  of  the  viscera, 
kidneys,  lungs,  &c.,  the  habits  of  the  patient,  her  digestive  powei-s, 
must  all  be  carefully  noted.  For  upon  a  consideration  of  these  points, 
not  only  does  the  prognosis  to  some  extent  depend,  but  also  the  nature 
and  duration  of  the  treatment  to  be  adopted  preparatory  to  tlie  opera- 
tion. Age  need  not  be  regarded  as  a  bar  to  operation.  Mr.  Bland 
Sutton  has  collected  eleven  cases  of  ovariotomy  in  women  over  80,  all 
of  whom  recovered  {Bland  Sutton,  loc.  cit.,  p.  175).  The  presence  of 
albumen  in  the  urine  should  not  be  regarded  as  necessarily  a  contra- 
indication to  operation.  Small  amounts  often  clear  up  after  the 
removal  of  the  tumour.  If  chronic  neiDhritis  is  known  to  be  present, 
the  operation  should  still  be  carried  out,  in  most  cases,  after  suitable 
preliminary  treatment. 

As  regards  difficulties  likely  to  be  met  with  in  the  course  of  the 
operation,  some  information  will  be  obtained  from  the  history  of  the 
patient  and  from  careful  examination.  Attacks  of  pain  will  point  to 
peritonitis  and  adhesions.  An  examination  of  the  tumour  will  give 
some  idea  of  its  mobility,  of  the  proportion  of  solid  matter,  &c. 

The  amount  of  skill  of  the  surgeon,  though  a  delicate  matter,  must  also 
be  mentioned.  No  one  should  operate  on  these  cases  who  has  not  had 
good  opportunities  of  seeing  others  operate  frequently,  and  no  one 
should  undertake  a  case  whose  ovariotomies  are,  at  the  most,  likely 
to  be  but  two  or  three  in  his  lifetime. 

Preparation  of  the  Patient. — The  patient  should  be  kept  quiet  for 
two  or  three  days  before  the  operation,  in  an  ordinary  uncomplicated 
case,  and  the  bowels  regulated.  The  diet  need  not  be  unduly  restricted 
or  altered,  be_yond  seeing  that  it  is  easily  digestible  and  nutritious. 
One  or  two  warm  baths  may  be  taken  on  the  day  or  two  before  the 
operation.  On  the  evening  preceding  the  operation  the  abdomen 
should  be  thoroughly  washed,  attention  being  paid  particularly  to  the 
navel.  It  is  better,  especially  in  a  delicate,  sensitive  patient,  to  defer 
the  shaving  of  the  pubes  until  she  is  under  the  angesthetic.  A  compress 
of  1-2000  perchloride  of  mercury  should  then  be  applied.  A  purge 
should  be  given  overnight,  followed  by  an  enema  in  the  morning.  On 
the  day  of  operation  a  light  breakfast  should  be  taken,  and  some  beef- 
tea  or  soup  about  10,  if  the  operation  is  to  take  place  about  2  p.m. 
When  the  patient,  warmly  clad,  especially  as  to  her  extremities,  conies 
in  to  take  an  anaesthetic,  only  two  or  three  faces  that  are  familiar  to  her 
should  be  present ;  when  she  is  iinder  the  anaesthetic  a  catheter  should 
be  passed,  if  the  bladder  has  not  been  emptied  beforehand. 

Preparation  of  Instruments,  &c. — The  room,  which  has  been 
thoroughly  cleansed,  and  not  rendered  too  comfortless  for  the  sake 
of  ventilation,  &c.,  should  have  a  temperature  of  about  65°.  A  good 
light,  and  one  likely  to  last,  should  be  secured.  The  table  should  be 
sufficiently  high  to  save  the  operator  stooping,  and  only  just  wide 
enough  to  hold  the  patient  comfortably.     It  will  be  found  an  advantage 


528  OPERATIONS  OX  THE  ABDOMEN. 

to  have  a  table  which  allows  of  the  patient  being  placed  in  the 
Trendelenberg,  or  raised  pelvic  position,  if  necessar3\  A  dozen  new 
Turkey  sponges,  chosen  for  their  even  softness  of  texture,  should  have 
been  carefully  prepared,  and  four  flat  ones  (not  too  large)  should  also 
be  provided.  ^  A  few  small  sponges,  ready  for  use  on  holders,  leave  no 
excuse  for  the  dividing  of  sponges  during  the  operation,  a  course  to 
be  unhesitatingly  condemned.  It  is  well  to  record  the  number  of 
sponges  and  Spencer  Wells's  forceps  on  a  slate.  Instead  of  sponges, 
o-auze  swabs  and  pads  may  be  employed  ;  these  must,  of  course,  be 
provided  in  larger  numbers  as  they  cannot  be  cleansed  after  use ;  they 
must  be  as  carefully  counted  before  and  after  the  operation  as  are 
the  sponges. 

The  following  should  be  in  readiness  :  Two  scalpels,  blunt-pointed 
bistoury,  steel  director,  Key's  director,  twelve  pairs  of  Spencer  Wells's 
forceps'  clamp  forceps,  cyst  forceps,  Spencer  Wells's  vulsellum-trocar* 
and  tubing,  blunt-pointed  scissors,  needles  (twelve  straight,  two  being 
threaded  on  each  suture  of  stout  silk  or  silk-worm  gut  for  closing  the 
abdominal  A\-ound,  and  fine  ones,  both  straight  and  curved,  for  under- 
running  any  bleeding  point  or  introducing  fine  sutures  if  any  of  the 
contents  of  the  abdomen  are  unavoidably  injured),  two  aneurysm-needles, 
pedicle  needle,  needle  holder,  two  retractors,  sponge  holders,  plenty  of 
silk  and  chromic-gut  ligatures  of  varving  sizes  (and  the  material  care- 
fully prepared,  including  some  stout  enough  for  the  pedicle),  two 
pairs  of  dissecting  forceps,  dressing  forceps,  drainage  tubes  (both  glass 
and  rubber),  Paquelin's  cauter}^  abundance  of  lysol  and  mercury  per- 
chloride  lotion,  a  foot-pan  to  stand  under  the  table,  two  others  to  wash 
the  sponges  in,  a  laryngeal  mirror  or  electric  lamp.  The  instruments 
should  stand,  in  two  tra^^s  or  pie-dishes,  on  a  small  wheel-table  close 
to  the  operator's  right  hand,  the  ligatures  and  sutures  should  be  in 
separate  porringers,  all  covered  with  cai'bolic  acid  (i  in  40)  or  lysol. 

In  addition  to  the  anaesthetist  two  assistants  will  be  found  amply 
sufficient,  one  to  stand  opposite  the  operator  to  assist  in  securing 
vessels,  to  help  with  the  tumour,  &c.,  whilst  the  second  will  hand 
instruments,  thread  needles,  prepare  ligatures,  and  so  on.  One  nurse 
will  be  required  to  wash  sponges  if  these  are  used,  and  another  to 
attend  to  the  nursing  operations  generally. 

The  Operation. 

Incision  of  Abdominal  Wall. — An  incision  in  the  median  line, 
reaching  from  just  below  the  umbilicus  to  within  two  inches  of 
the  pubes,  is  made  through  skin  and  fat.  There  is  no  object  in 
having  the  incision  more  than  three  inches  long  to  commence  with, 
as  it  can  be  lengthened  as  required  subsequently.  After  dividing  the 
skin  and  fat,  the  layer  of  fascia  which  forms  the  sheath  of  the  recti 
muscles  comes  into  view.  If  the  muscles  are  in  apposition,  one  or  both 
of  them  will  be  exposed  on  incising  the  fascia  ;  the  interval  between 
them  should  be  sought  for  and  the  two  muscles  separated  for  the  length 
of  the  incision.  If  the  linea  alba  is  missed,  and  a  difficult}'-  is  ex- 
perienced in  finding  the  median  line,  a  director  or  the  handle  of  the 
scalpel  should  be  introduced  beneath  the  fascia  ;  the  director  will  be 
arrested  on  the  side  on  which  the  linea  alba  lies. 


*  One  or  two  smaller  trocai's  should  also  be  in  readiness. 


0\'AI{10T0My.  529 

If  the  recti  are  separated  an  incision  through  the  fascia  in  the 
median  line  at  once  exposes  the  sub-peritonaeal  fat  and  peritona3nni. 
Before  this  is  incised  Spencer  Wells's  forceps  are  applied  to  every 
bleeding  point ;  these  ma}'  be  left  on  until  the  operation  is  concluded ; 
an}'  bleeding  points  then  persisting  should  be  treated  by  torsion  and 
not  by  ligature,  as  these  latter  weaken  the  cicatrix.  The  jDeritonieum, 
readily  recognised,  when  healthy,  by  its  delicate  fasciculation  and  trans- 
lucency,  is  carefully  picked  up  by  a  pair  of  forceps  so  as  to  include 
nothing  else,  and  an  incision  is  made  in  it  horizontally  with  a  knife. 
As  soon  as  the  peritonseal  cavity  is  opened  the  intestines  fall  away  from 
the  abdominal  wall.  The  peritonaeum  is  then  slit  up  on  two  fingers 
for  the  length  of  the  incision ;  the  fingers  used  in  this  way  as  a  director 
are  enabled  to  detect  the  height  to  \\'hich  the  bladder  comes  at  the 
lower  part  of  the  wound,  and  so  determine  the  limit  to  which  the 
peritonasai  incision  may  safely  be  carried  below. 

Mr.  Doran  (Ann.  of  Swg.,  May  1888)  thinks  a  mistake  is  often 
made  in  not  bringing  the  incision  near  enough  to  the  pubes,  which 
may  cause  much  trouble  when  the  pedicle  has  to  be  drawn  out,  and 
greatly  impede  a  thorough  exploration  of  the  pelvis. 

Care  should  be  taken  not  to  mistake  the  sub-peritonasal  fat  for 
omentum,  as  this  may  lead  to  extensive  stripping  off  of  the  peritoneeum 
from  the  abdominal  wall,  an  accident  likely  to  be  followed  by  sloughing 
of  this  structure. 

In  an  easy  case  without  parietal  adhesions  the  pearl}^  glistening  cyst 
comes  into  view  as  soon  as  the  peritona3um  is  incised ;  but  if  the  peri- 
tonaeum is  thickened  and  adherent  to  the  cyst  there  may  be  the  greatest 
difficulty  in  deciding  when  this  is  reached,  and  the  incision  may  even 
be  carried  through  the  cyst-wall.  In  cases  of  difficulty  the  incision 
should  be  prolonged  upwards  to  the  left  of  the  umbilicus  until  a  spot 
free  from  adhesions  is  found. 

AVhen  tiie  tumour  is  exposed  it  should  be  examined  carefully  by  eye 
and  hand.  Its  nature  should  be  noted,  whether  cystic  or  solid,  or 
partially  solid,  whether  a  dermoid  or  inflamed  ■  the  presence  of  adhe- 
sions should  be  ascertained  or  secondary  malignant  deposits,  rendering- 
further  oi)eration  unadvisable.  If  we  are  dealing  with  an  uncomplicated 
cystic  tumoui"  of  the  ovary,  the  first  proceeding  is  to  tap  it.  To 
separate  adhesions  before  tapping  is,  in  Mr.  Thornton's  words  (Diet, 
of  Sunj.,  vol.  ii.  p.  153),  "bad  practice,  because  if  the}^  are  separated 
while  the  parietes  and  cyst  wall  are  both  stretched  by  the  fluid,  all  the 
little  vessels  in  them  bleed,  and  very  serious  haemorrhage  may  occur 
out  of  sight  during  the  subsequent  emptying  of  the  cyst ;  whereas 
if  the  cj^st  be  first  tapped,  the  contraction  of  both  parietes  and  cyst 
wall  closes  the  smaller  vessels." 

Empti/ing  the  Cijd. — The  abdominal  incision  should  be  packed  round 
to  ]n-event  fluid  running  back  into  the  abdominal  cavity.  The  cyst 
is  next  tapped  b}'  carefully  plunging  in  a  Spencer  Wells's  trocar, 
then  guarding  the  point  with  the  inner  tube,  and  as  soon  as  the 
walls  of  the  cyst  are  rendered  lax  enough  by  the  escape  of  the  con- 
tents, attaching  the  claws  to  the  cyst  wall  so  as  to  keep  this  on  the 
trocar,  as  forward  traction  is  made. 

Dr.  Baldy  (Si/st.  of  Gijncecol.,   1894)  points  out  that    the  puncture 
should  not  be  made  at  the  lower  angle  of  the  wound,  for  the  reason 
VOL.  II.  34 


530  OPERATIONS  OX  THE  ABDOMEX. 

that  as  the  cyst  empties  it  retracts,  and  leaves  tlie  opening  situated 
below  the  wound,  increasing  the  difficulty  of  preventing  fluid  from 
entering  the  peritonseal  cavity.  As  soon  as  the  trocar  is  inserted 
into  the  cyst,  the  assistant  should  place  a  hand  low  down  on  each 
side  of  the  abdomen,  and  press  steadily  and  firmh'.  By  this  means 
he  not  only  forces  out  the  fluid  from  the  cyst,  but  keeps  the  abdominal 
incision  taut  over  the  tumour,  thus  preventing  the  contents  of  the  cyst 
from  running  into  the  peritoneal  cavit}'.  As  the  cyst  empties  traction 
is  applied  to  it  by  means  of  the  claws  of  the  trocar  or  bj^  other  forceps, 
and  if  there  are  no  adhesions  it  is  readily  brought  out  of  the  wound. 

If  there  is  difficulty  in  delivering  the  tumour,  and  it  is  clear,  from  the 
bulk  of  the  cyst  remaining  after  tapping,  that  it  is  multilocular  or  solid, 
it  will  have  to  be  further  reduced  in  size  before  extraction.  If  it  is 
multilocular  it  must  be  tapped  again  in  two  or  three  more  places  by 
removing  the  trocar  and  closing  the  puncture  with  cyst  forceps,  and 
then,  while  the  cyst  is  dragged  forward  and  steadied,  the  first  trocar  or 
a  smaller  one  is  thrust  in  at  other  spots  where  fluid  is  still  present. 
This  is  a  better  practice  than  thrusting  the  trocar  from  the  first 
puncture  into  other  parts  of  the  cyst  in  the  dark.  If  this  latter 
method  is  adopted,  the  hand  should  first  be  pressed  into  the  abdomen 
to  make  sure  that  the  trocar  does  not  perforate  the  cyst  wall  and 
injure  the  viscera.  In  cases  in  which  the  tumour  is  composed  of  a 
large  number  of  small  cysts,  or  in  which  the  contents  are  so  viscid  that 
they  will  not  escape  through  the  trocar,  the  opening  should  be 
enlarged  and  the  hand  passed  into  the  cyst  to  break  down  the  nume- 
rous septa  or  scoop  out  the  viscid  contents. 

If  the  bulk  of  the  cyst  is  solid,  the  trocar  puncture  having  been 
enlarged  and  clamp  forceps  firmly  keeping  forward  the  edges,  the 
surgeon  first  introduces  two  or  three,  then,  perhaps,  all  the  fingers  of 
one  hand  and  scoops  out  the  solid  material  till  the  bulk  of  the  cjst  is 
sufficiently  reduced  to  come  through  his  incision.  It  is  preferable, 
however,  to  enlarge  the  incision  upwards  sufficiently  to  allow  of  the 
mass  being  brought  out  entire,  its  long  axis  being  tilted  into  that  of  the 
wound.  In  these  cases  it  is  especiallj^  important  to  avoid  any  leakage 
of  the  contents  into  the  peritonaeal  cavity,  as  portions  of  the  tumour 
thus  carried  in  may  give  rise  to  a  recurrence  of  growth. 

If  the  wound  requires  enlargement,  this  is  best  done  with  a  blunt- 
pointed  straight  bistoury  or  a  pair  of  scissors  and  the  use  of  two  fingers 
as  a  director,  the  incision  being  carried  to  the  left  of  the  umbilicus  so 
as  to  avoid  any  still  open  vessel  in  the  round  ligament. 

The  enlargement  of  the  wound  may  be  found  necessary  when  the 
ovarian  tumour  is  solid  or  contains  such  a  proportion  of  solid  material 
as  to  render  its  delivery  through  the  original  incision  difficult. 
When  feasible,  this  is  a  better  plan  in  the  latter  case  than  scooping 
out  the  contents,  as  this  proceeding  is  often  attended  with  considerable 
haemorrhage,  and  is,  moreover,  likely  to  be  followed  b}^  reinfection  of 
the  peritonseal  cavity.  The  wound  should  be  enlarged  when,  from  the 
previous  history  or  the  appearance  of  the  tumour,  there  is  reason  to 
believe  that  suppuration  has  occurred.  Many  surgeons  prefer  to 
remove  dermoids,  unless  of  large  size,  entire,  to  obviate  the  risk  of 
the  oily  contents  escaping  into  the  abdominal  cavity. 

Treatment  of  Adhesions. — As  the  cyst  is  emptied  and  drawn  forwards. 


OVARIOTOMY.  53 1 

any  adhesions  that  are  present  must  be  dealt  with,  and  the  ease  with 
which  they  are  separated  will  depend  upon  whether  they  are  recent  or 
not.  Those  between  the  tumour  and  abdominal  wall  are  readily 
separated,  when  recent,  by  sweeping  the  hand  between  the  two 
adherent  surfaces.  If  of  longer  duration  the  separation  must  be 
effected,  bit  by  bit,  with  the  finger-nail  or  scissors,  any  persistent 
bleeding  points  being  secured  by  Spencer  Wells's  forceps  and  tied. 
Another  method  is  to  under-run  any  bleeding  points,  especially  any 
obstinate  ones  in  the  parietal  peritonaeum.  Adhesions  to  the  omentum, 
which  are  the  most  common,  must  be  ligatured  and  divided,  the  number 
of  ligatures  used  depending  on  the  extent  of  the  adherent  omentum. 
Mr.  Herman  (Diseases  of  Women,  1898,  p.  797)  points  out  that  holes 
frequently  exist  in  large  pieces  of  adherent  omentum,  and  he  advises 
that  in  cutting  the  omentum  away  the  incisions  should  be  carried 
through  these  holes  to  obviate  any  subsequent  risk  of  intestines  being 
strangulated  in  them.  Intestinal  and  other  visceral  adhesions  may 
present  considerable  difficulties.  If  the  bowel  is  adherent  it  should 
be  ver}^  carefully  peeled  by  means  of  the  thumb-nail  from  the  cyst.  If 
it  cannot  be  detached  in  this  way  a  thin  strip  of  the  cyst  wall  should 
be  cut  away  and  left  adherent  to  the  intestines.  Firm  adhesions  in  the 
pelvis  present  the  most  difficulty,  and  in  the  separation  of  them  by 
means  of  the  fingers  a  hole  may  be  torn  in  the  rectum.  Injury  to  large 
vessels  is  not  common.  In  Dr.  Baldy's  "  Gj'naecology,"  however,  a  case 
is  recorded  in  which  death  resulted  from  hasmorrhage  due  to  injur}*  of  a 
large  vein  in  the  removal  of  an  ovarian  cyst.  Though  bleeding  from 
large  vessels  is  not  common,  it  is  especially  in  cases  of  extensive  pelvic 
adhesions  that  we  get  troublesome  oozing.  If  the  bleeding  is  coming 
from  one  or  two  points  it  may  be  possible  to  seize  them  with  artery 
forceps  and  secure  them  with  a  ligature.  This  procedure  will  be  much 
facilitated  b}^  having  the  patient  in  the  raised  pelvis  position.  If,  as  is 
commonlj^  the  case,  the  oozing  is  general,  the  peUdc  cavity  should  be 
firmly  packed  with  long  strips  of  sterilised  or  iodoform  gauze,  the  ends 
of  which  are  brought  out  through  the  lower  part  of  the  wound.  The 
sutures  should  be  introduced  as  usual  into  the  lower  part  of  the 
abdominal  incision,  but  should  be  left  untied,  ready  to  bring  the  edges 
of  the  wound  together  when  the  plug  is  removed.  The  gauze  should 
be  taken  out  fort^'-eight  hours  after  the  operation.  By  that  time  it 
will  have  served  its  purpose,  the  arrest  of  the  oozing.  It  will  be  found 
that  the  plug  is  more  easily  removed  then  than  later,  though  some 
operators  recommend  that  it  should  be  left  in  a  week.  This  method 
of  treatment  by  packing  is  a  much  more  relial)le  and,  on  the  whole, 
safer  method  than  the  older  ones  of  cauterisation  or  touching  with  solid 
perchloride  of  iron.  If  packing  with  gauze  is  used  for  troublesome 
pelvic  oozing,  the  cautery  will  be  very  seldom  required.  Mr.  Herman, 
who  has  never  had  occasion  to  use  the  cautery,  says,  with  regard  to 
its  employment  in  the  pelvis — "  Large  vessels  lie  so  close  under  the 
peritontBum  that  I  should  fear  to  burn  extensively  in  this  region." 
With  regard  to  the  use  of  iron  perchloride,  the  only  condition  that 
demands  its  use,  viz.,  general  oozing,  is  better  met  by  the  use  of  the 
gauze  tampon.* 

*  Mr.  Thornton  (Inc.  supra  cit.')  gives  the  following  advice  respecting  the  use  of  iron 
perchloride: — '-The  surfaces  to  be  touched  should  be  dried  with  a  sponge;   then  a 


532 


OPERATIONS  ON  THE  ABDOMEN. 


Fig.  211. 


Treatmenf  of  Pedicle. — When  the  cyst  has  been  sufficiently  Ijvought 
outside,  the  pedicle  is  dealt  Avith. 

The  centre  of  the  pedicle  being  found  by  unfolding  it,  a  blunt 
pedicle  needle  loaded  with  silk  (No.  4)  is  made  to  perforate  it 
here  at  a  spot  devoid  of  vessels.  The  loop  of  silk  being  drawn 
through  and  the  needle  withdrawn,  the  loop  is  cut,  and  the  two 
ligatures  tied  firmly  round  the  two  halves  of  the  pedicle.      To  make 

the  silk  hold  in  a  stout  pedicle, 
it  is  well  to  loop  the  ligatures 
round  some  blunt  instruments, 
so  as  to  tie  them  with  sufficient 
force.  When  they  are  both  tied, 
one  is  cut  short,  while  the  other 
is  thrown  round  the  whole  pedicle 
and  tied  again.  The  cyst  is  then 
cut  away,  not  more  than  three- 
quarters  of  an  inch  and  not  less 
than  half  an  inch,  from  the  liga- 
tures. When  this  is  done,  the 
cut  end  is  carefull}'  examined, 
to  make  sure  that  no  bleeding- 
is  taking  place.  The  j^edicle  is 
then  allowed  to  drop  in,  and 
the  finger,  following  it  down 
up  the  other  ovary.  If  this  is 
When  the  pedicle  is  verv  broad. 
The  second  must  be 


(Dorau 


Fig.  212. 


to    the    uterus,    finds    and    hooks 

found  enlarged,  it  must  be  removed. 

a  second  or  a  third  transfixion  A\'ill  be  needed 

thus  performed  :  The  thread  for  the  outer  loop  (a,  Fig.  212)  is  twisted, 

on  one  side  of  the  pedicle  round  the  outer  thread  (b),  then  the  outer 

loop  is  tied.     The  pedicle-needle  (a  long  unhandled  one  with  a   large 

eye  is  the  best)  is  then  threaded,  first  with 

a    single   ligature   (c),   and    then  with    one 

end  (h)  of  the  untied  thread  already  passed  c  h  a- 

through  the    pedicle.      The    transrixion    is  /■\  /"\  /\ 

then  performed  (Fig.  212).    The  third  thread  /     \        /    \       /   \ 

(c)  must  be  once  twisted  around  the  second 

(h) ;   this  is  best  done,  perhaps,  on  the  side 

where  (b)  forms  a  loop  (Fig.  212).     Then. 

on  the  opposite  side,  the  two  free  ends  of 

the  second  thread  (h)  are  firmly  tied.     The  (Doran.) 

ends  of  the  third  thread  (c)  are  then  tied  on 

the  inner  side  of  the  pedicle.     The  threads  will  then  lie  as  in  Fig.  212. 

firmly  interlocked  and   holding  the    pedicle  tightly.     Should   a  third 

transfixion  l)e  required,   the  third  thread,  instead  of  being  tied,  nmst 

be  threaded  on  the  needle  in  company  with  a  fourth,  and  the  process 

just  described  repeated,  care  being  taken  to  interlock  the  threads  as 

small  sponge,  well-wTung,  should  be  smeared  lightly  with  the  solid  perchloride,  and 
firmly  pressed  against  the  bleeding  surface  tiU  the  oozing  stops  ;  a  large  flat  sponge 
should  be  spread  under  the  surfaces  thus  treated,  to  prevent  any  of  the  acid  serum, 
which  runs  away  immediately  after  the  application  of  the  iron,  getting  on  to  the 
intestines.  Oozing  surfaces  in  the  pelvis  are  treated  in  the  same  way,  the  intestines 
being  first  drawn  out  of  the  way  and  protected  by  sponges." 


OVARIOTOMY.  533 

before.  If  this  precaution  be  not  taken,  the  unlocked  threads  pulling 
in  different  directions  will  tend  to  tear  the  pedicle  apart  at  the  point 
of  transfixion,  and  vessels  may  easily  escape  being  commanded.  As 
each  of  the  above  loops  is  tied,  the  ends  of  the  thread  must  be  cut 
short  or  needless  confusion  will  be  entailed. 

TJie  Toilet  of  the  Peritoiuviim. — The  operator  now  scrutinises  the 
parts,  removes  any  jagged  omentum  or  bands  of  adhesions,  arrests 
any  still  bleeding  points,  takes  out  anj^  sponges  which  he  may  have 
inserted  and  has  them  all  counted.  The  next  step  is  to  sponge  out 
thoroughl}^  the  pelvis,  the  spaces  in  front  and  behind  the  uterus,  and 
those  on  either  side  of  the  vertebral  column.  This  is  effected  by 
introducing  again  and  again  aseptic  sponges  or  sterilised  gauze  swabs 
on  sponge  forceps  until  they  return  dry  and  colourless.  In  the  great 
majority  of  cases  this  will  be  sufficient,  and  many  operators  employ 
practically  no  other  procedure.  If,  however,  a  cyst  has  burst  during 
the  handling  of  the  tumour,  as  sometimes  happens  when  the  wall  is 
thin  or  necrotic,  and  viscid  contents  or,  perhaps,  papillary  gi'owths  have 
escaped  into  the  peritonteal  cavity,  it  is  difficult  without  undue  manipu- 
lation of  the  viscera  to  get  the  abdominal  cavity  clean.  Under  these 
circumstances  it  is  preferable  to  wash  out  with  warm  sterilised  water, 
or  sterilised  water  to  which  "6  per  cent,  of  common  salt  has  been 
added.  This  is  especially  indicated  where  growth  has  escaped  into 
the  peritonagal  cavity  from  a  papillary  cyst,  on  account  of  the  possibility 
of  reinfection  from  a  portion  of  growth  left  behind. 

Suture  of  AJxlominal  Wound. — The  abdominal  wound  may  be  closed 
either  by  using  one  row  of  sutures  which  pass  through  skin,  muscle, 
and  peritonaeum,  or  by  securing  the  different  layers  separately.  One 
row  only  of  sutures  should  be  used  in  cases  in  which  drainage 
is  employed,  or  in  which  the  contents,  though  freely  removed,  were 
septic,  or  again,  in  cases  in  which  a  second  operation  appears  probable. 
The  introduction  of  a  single  layer  is  effected  as  follows :  A  flat  sponge 
being  introduced  to  catcla  any  blood,  the  abdominal  wound  is  closed 
b}^  means  of  sutures  of  stout  silk,  or  preferably  silk-worm  gut. 
These  should  be  carried  through  peritonEeum,  muscle,  and  skin,  care 
being  taken,  as  Mr.  Herman  points  out.  that  the  stitches  pass  through 
the  edge  of  the  peritoneum  only,  so  that  this  structure  is  not  tucked 
in  between  the  edges  of  the  wound.  Not  only  should  a  good  bunch 
of  muscle  be  included,  but  also  the  fibrous  sheath  overlying  it.  The 
sutures  should  pass  through  the  skin  about  a  quai'ter  of  an  inch  from 
the  edge  of  the  wound,  and  they  should  be  inserted  about  half  an  inch 
from  each  other.  When  all  the  sutures  have  been  introduced  they 
are  collected  near  their  ends  on  either  side  with  pressure  forceps. 
(Fig.  213).  The  operator  then  parts  the  sutures,  hooking  them  up  and 
down  so  as  to  obtain  free  access  to  the  abdominal  cavity  without  an}' 
risk  of  pulling  out  a  suture.  The  flat  sponge  is  now  withdrawn  and 
the  sutui'es  tied,  care  being  taken  that  neither  omentum  nor  intestines 
become  caught  in  the  loop.  Superficial  sutures  of  fine  silk  or  horse- 
hair should  be  emploj^ed  to  accurately  coapt  the  edges  of  the  skin. 

If  the  layers  of  the  abdominal  wall  are  to  be  sewn  up  separately, 
the  first  procedure  is  to  shut  off  the  peritonteal  cavity  by  laringing 
the  edges  of  the  peritoneum  together  with  a  continuous  suture  of 
fine   silk.     The   recti   are  then  approximated,   either  by  a  continuous 


534 


OPERATIONS  OX  THE  ABDOMEN. 


silk  suture  or  by  interrupted  sutures  of  the  same  material,  care  being 
taken  to  bring  together  the  edges  of  the  fibrous  layer  overljdng  the 
muscle.  The  edges  of  the  skin  are  finally  sewn  together  in  the  same 
way. 

Drainaije. — ^Different  operators  vary  much  in  their  practice  as  regards 
drainage,  and  it  is  difficult  to  lay  down  any  hard-and-fast  rules  as  to 
when  to  emplo}'  it.  Undoubtedly  the  tendency  is  to  employ  it  less  and 
less.  Experiments  carried  out  within  the  last  few  3'ears  on  the  absorp- 
tive powers  of  the  peritoneeum  have  taught  us  that  this  structure,  when 
in  a  normal  condition,  is  capable  of  absorbing  large  quantities  of  fluid, 
and  also  of  disposing  of  a  considerable  number  of  pyogenic  organisms 

Fig.  213. 


(Doran.) 


introduced  into  the  abdominal  cavity.  We  have  to  bear  in  mind,  however, 
that  a  peritonaeum  thickened  by  inflammation,  such  as  we  find  in  some 
cases  of  ovarian  tumour,  has  its  functions  impaired,  and  is  not  in  a 
condition  to  dispose  of  large  quantities  of  fluid  or  many  organisms. 
Consequently  fluid  collecting  in  the  abdominal  cavit}^  provides  a  ready 
medium  for  the  growth  of  any  organisms  accidentally  introduced. 

Dr.  Jellett  (Pract.  of  Gi/ncBCol.,  1900,  p.  287)  puts  this  question  of 
drainage  very  clearly.  "  It  must  be  regarded,"  he  says,  "  as  a  line  of 
treatment  whose  general  effect  is  by  no  means  beneficial,  but  which  may 
have  to  be  used  at  times  in  order  to  guard  against  a  greater  danger." 
The  risks  of  drainage  should  be  clearl}^  recognised.  One  serious  result 
is  the  weakening  of  the  abdominal  scar  that  attends  its  use,  AAith  the 
subsequent  formation  of  a  hernia.  The  drain  may  be  a  cause  of  re- 
infection of  the  abdominal  cavity,  and  A^•hen  a  hard  glass  tube  is  em- 
ployed, may,  by  pressure  on  the  bowel,  lead  to  the  formation  of  a  fiscal 


OVAlflOTO.MY.  535 

fistula.  There  is  one  condition  in  which  drainage  is  certainh*  called  for, 
and  that  is  when  any  septic  material,  as  from  a  suppurating  cyst  or  a 
pyo- salpinx,  has  entered  the  peritona3al  cavity,  or  when  an}-  septic  focus 
has  been  imperfectly  removed. 

Drainage  is  commonly  made  use  of  after  the  separation  of  extensive 
adhesions.  In  such  cases  the  surgeon  must  use  his  own  judgment.  He 
should  bear  in  mind  the  fact  that  the  absorptive  powers  of  the  peritoneum 
in  such  cases  are  impaired,  and  if  he  thinks  that  more  exudation  is 
poured  out  than  the  peritonaeum  can  deal  with,  he  must  employ  some 
form  of  drainage.  For  this  purpose  a  glass  tube  (Keith's)  is  commonly 
made  use  of.  One  end  rests  at  the  bottom  of  Douglas's  pouch  without 
pressing  on  the  rectum,  the  other  passes  through  a  thin  sheet  of  india- 
rubber,  its  neck  being  firmly  gripped  by  a  hole  in  this.  One  or  two 
sutures  should  be  passed  in  the  usual  way  through  the  abdominal 
wound,  above  and  below  the  tube,  but  left  untied  until  the  tube  is 
removed.  A  sponge  is  placed  on  the  end  of  the  tube  to  absorb  dis- 
charges, and  the  india-rubber  sheeting  wrapped  round  it  to  prevent 
soiling  of  the  dressings.  The  sponge  should  be  changed  at  first  every 
hour,  and  this  is  done  without  disturbing  the  dressings  over  the  wound ; 
later  on  the  change  should  be  effected  ever}^  two  or  three  or  more  hours. 
At  the  same  time  as  the  sponge  is  changed  the  fluid  should  be  sucked 
out  of  the  drainage  tube  by  means  of  a  glass  syringe  with  a  piece  of 
india-rubber  tubing  attached.  The  syringe  and  tubing  should  be  boiled 
before  being  used,  and  the  most  scrupulous  precautions  taken  against 
the  introductions  of  organisms  from  without.  It  is  difficult  to  lay  down 
rules  with  regard  to  the  length  of  time  drainage  should  be  employed. 
When  used  on  account  of  oozing  from  extensive  raw  surfaces  one  to  two 
days  will  usually  suffice.  If  employed  for  a  septic  case  drainage  may 
be  dispensed  with  as  soon  as  a  bacteriological  examination  shows  the 
discharge  to  be  sterile.  When,  on  account  of  persistence  of  purulent 
discharge,  drainage  is  required  for  some  time,  the  glass  tube  should  be 
replaced  in  a  few  days'  time  by  a  rubber  one.  Mr.  Herman  recommends 
that  it  should  be  so  replaced  at  the  end  of  twenty-four  hours  in  all  cases 
where  longer  drainage  is  required.  Owing  to  the  fact  that  a  hard  tube 
is  likely  to  produce  a  fascal  fistula  by  pressure  on  the  bowel,  and  owing 
to  the  danger  of  reinfection  that  attends  its  use,  many  surgeons  have 
discarded  it,  and  now  employ  gauze  instead.  Either  sterilised  or  iodo- 
form gauze  may  be  used.  It  should  be  cut  into  strips  and  its  edges 
turned  in  and  sewn  together  to  prevent  the  possibility  of  shreds  being 
detached  and  left  behind  in  the  wound.  As  it  soon  ceases  to  act  as  a 
drain  it  should  be  removed  twentj'-four  to  forty-eight  hours  later,  fresh 
strips  being  replaced  if  necessary.  The  advantages  in  certain  cases  of 
drainage  through  the  vagina  are  pointed  out  b}^  Dr.  Jellett  (loc.  supra 
cit.),  and  he  considers  that  with  a  healthy  vagina,  drainage  through  the 
bottom  of  Douglas's  pouch  is  the  correct  treatment  in  the  majority  of 
cases. 

Encapsuled  Ovarian  Cysts. — Ci/sts  of  the  Broad  Lijament. — Tnira- 
ligamentous  Cysts. — Cases  are  occasionally  met  with  in  which  the  cyst 
growing  between  the  layers  of  the  broad  ligament  is  imperfect!}' 
encapsuled  and  has  no  pedicle  that  can  be  ligatured.  In  these  cases 
an  attempt  should  be  made  to  enucleate  the  tumour  after  making  an 
incision  through  the  peritonteal  covering.     Mr.  Thornton  {Bid.  Sun/ery, 


536  OPEEATIONS  OX  THE  ABDOMEN. 

vol.  ii.  p.  155)  has  pointed  out  the  advisability  of  isolating  at  an  early 
stage  the  vessels  and  ligaturing  them.  Dr.  Kelly  {Oper.  GyntvcoL,  1898, 
vol.  ii.  p.  303),  who  also  di-aws  attention  to  the  importance  of  securing 
the  vessels  early  in  the  oj^eration,  points  out  that  the  blood-supply  is 
derived  from  the  ovarian  and  the  terminal  branches  of  the  uterine 
vessels,  and  that  these  should  be  sought  for,  the  former  on  the  side 
of  the  pelvic  brim,  the  latter  on  the  uterine  side  of  the  cyst,  after 
division  of  the  peritonaeum.  If  these  are  tied  at  once  there  need  be 
but  little  hsemorrhage  throughout  the  operation.  The  main  blood- 
supply  having  been  secured  in  this  way,  the  tumour  should  be  enu- 
cleated by  separating  with  the  fingers  the  loose  connective  tissue 
that  holds  it  in  position.  The  removal  of  the  cyst  will  be  facilitated 
by  emptying  it  of  its  contents  with  a  trocar  in  the  usual  way.  Any 
bleeding  points  in  the  capsule  should  be  seized  with  pressure  forceps 
and  secured.  "  In  performing  these  enucleations  the  operator  must 
always  bear  in  mind  the  fact  that  he  is  constantly  brought  into 
dangerously  close  relations  with  bladder  and  ureters,  rectum  and 
sigmoid  flexure,  or  caecum  and  appendix.  The  large  iliac  vessels 
are  also  occasionally  incorporated  with  the  capsule "  (Mr.  Thornton, 
loc.  supra  ciL). 

After  the  removal  of  the  cyst  the  capsule  requires  attention.  If  it 
is  very  redundant  it  ma}'  be  gathered  up  into  a  loose  fold,  transfixed 
and  tied,  like  an  ordinary  pedicle  (Mr.  Bland  Sutton,  Surg.  Bis.  of 
Ovaries,  1896,  p.  372).  If  the  cavity  is  small  and  there  is  no  oozing, 
the  cut  edges  of  the  peritonasum  should  be  drawn  together  by  a  con- 
tinuous silk  ligature.  If,  hoAvever,  there  is  much  oozing,  the  edges  of 
the  cyst  should  be  secured  to  the  lower  part  of  the  abdominal  wound 
and  its  interior  packed  with  gauze  strips.  Sometimes  it  is  found  that 
the  cyst  is  so  firmh-  attached  to  important  structures  that  its  removal 
becomes  an  impossibility.  The  edges  of  the  cyst  and  the  capsule  must 
then  be  attached  to  the  abdominal  wound  and  the  cavity  drained.  Such 
a  procedure  is  not  entirely  satisfactory,  as  the  cyst  is  likely  to  refill 
later.  When  intra-ligamentary  growths  occur  on  both  sides.  Dr.  Kelly 
considers  that  it  is  easier  and  Tjetter  to  remove  uterus  and  tumours 
together,  the  method  adopted  being  practically  the  same  as  that  em- 
ployed by  him  for  hysterectomy. 

Incomplete  Ovariotomy. — The  surgeon  may  be  compelled,  very  early 
in  the  case,  to  abandon  his  operation.  This  will  be  rendered  necessary 
by  the  following  conditions: — (i)  When  the  tumour  is  malignant  and 
has  infiltrated  tissues  which  cannot  be  safely  removed,  or  when  secon- 
dary nodules  are  found  in  the  abdominal  cavity.  (2)  When  the 
peritongeum  is  found  covered  with  papillary  growths,  the  result  of 
infection  from  a  papillary  cyst.  Dr.  H.  A.  Kelh^  (loc.  supra  cit.,  vol.  ii. 
p.  294)  advises  removal  of  the  mother-tumour  whenever  it  is  possible, 
as  he  considers  it  not  onh'  relieves  the  pressure  of  the  ascites,  but 
checks  the  rapidit}^  of  the  growth.  Moreover,  cases  have  been  recorded 
by  Mr.  K.  Thornton  and  others  where  a  disappearance  of  the  secondary 
papillary  growths  and  a  freedom  from  recurrence  have  resulted  from 
this  line  of  treatment.  (3)  When  the  base  of  the  cyst,  whether  intra- 
ligamentary  or  not,  is  irremovable,  deep  in  the  pelvis  and  adherent  to 
the  ureters,  large  vessels,  or  adjacent  viscera.  The  surgeon  must  then 
empty  the  cj^st  of  its  contents,  and  suture  its  cut  edge  to  the  abdominal 


OYAPJOTOMY.  537 

incision,  all  superfluous  portions  of  the  cyst  being  cut  away.  Before 
doing  this  he  must  check  all  hfemorrhage,  inspect  any  possibly  damaged 
viscera,  and  carefully  cleanse  the  back  of  the  tiimour  and  the  parts 
behind  it.  The  remains  of  the  cyst,  after  being  carefully  sutured  to  the 
lower  part  of  the  abdominal  incision  so  as  to  entirely  shut  off  the 
periton£eal  cavity,  should  be  packed  with  iodoform  gauze.  When  the 
cyst  contains  solid  growth  an  attempt  should  be  made  to  remove  this 
from  the  portion  of  cyst  left  behind,  else,  as  Mr.  Doran  points  out, 
both  sepsis  and  recurrence  will  be  ver}*  probable. 

Accidents  during  Ovariotomy. 

(i)  Siincojie. — This  appears  to  be  brought  about  in  some  cases  by  too 
rapid  emptying  of  large  cj'sts.  The  pressure  on  the  abdominal  vessels 
is  relaxed,  and  they  become  filled  with  blood  at  the  expense  of  the  rest 
of  the  body.  This  accident  should  be  avoided  by  slowly  drawing  off 
the  contents  of  large  cysts.  When  it  occurs  it  should  be  treated  by 
lowei'ing  the  head,  keeping  the  patient  warm,  and  administering  brandy 
subcutaneously. 

(2)  Vomitiru/. — This  chiefly  harasses  by  straining  the  intestines  out 
of  the  abdomen.  If  prolonged,  the  operation  must  be  completed  as 
soon  as  possible,  an  assistant  keeping  the  viscera  in  place  with  a  flat 
sponge  or  gauze  pad. 

(3)  SeiKiration  of  the  Parietal  Peritonceum. — It  has  already  been 
pointed  out  that  this  is  due  to  the  operator  mistaking  the  subperitonasal 
fat  for  omentum.     It  is  an  accident  that  may  be  avoided  by  care. 

(4)  Buijiure  of  the  Cyst. — This  accident  may  be  expected  when  the 
walls  are  thin,  necrotic,  or  softened  by  recent  inflammation.  In  such 
cases  the  cj'st  should  be  carefully  handled,  suspicious  spots  being  kept 
well  out  of  the  wound  or  packed  around  with  sponges.  If  rupture 
occurs  the  abdomen  should  be  well  irrigated  with  warm  boiled  water, 
and  if  the  contents  of  the  cyst  are  suppurating,  drained  subsequently. 

(5^  Lijvries  to  Viscera. — Of  these  the  bladder,  small  intestines,  rectum. 
and  ureter  are  most  likely  to  sufier.  The  bladder  may  be  injured 
during  the  abdominal  incision  owing  to  its  being  drawn  up.  This, 
however,  is  not  so  likely  to  happen  as  in  operations  for  fibroids.  Or  it 
may  be  opened  in  the  course  of  removal  of  the  tumour.  Treatment 
consists  in  immediate  suture  of  the  organ,  and  subsequent  drainage  by 
catheter  to  prevent  distension.  The  intestine  is  most  likely  to  be 
injured  in  the  separation  of  adhesions.  When  possible  the  wound  in 
the  bowel  should  be  at  once  sutured.  If  the  damage  is  more  extensive 
the  question  of  resection  of  a  portion  of  gut  will  arise.  The  rectum  is 
sometimes  torn  in  the  separation  of  firm  adhesions  in  the  pelvis.  The 
operator  should  attempt  to  sew  up  the  rent,  a  proceeding  that  will  be 
much  facilitated  by  the  raised-pelvis  position  and  a  good  light.  Often, 
suturing  will  be  found  to  be  impossible,  and  in  such  case  the  neighbour- 
hood of  the  injury  should  be  well  packed  with  iodoform  gauze,  the  ends 
of  which  are  left  out  of  the  abdominal  wound.  Sloughing  of  the  bowel 
sometimes  occiirs  after  the  operation,  leading  to  the  formation  of  a 
faecal  fistula.  This  is  owing  in  some  cases  to  injury  of  the  intestine 
during  the  operation,  in  others  to  the  pi'essure  of  the  glass  tube  used 
for  drainage.  For  the  treatment  of  cases  in  which  the  ureter  is  injured 
the  chapter  on  that  subject  should  be  consulted  (p.  i/O). 

(6)  Severe  Hannoi'rhage. — It  has  already  been  mentioned  that  severe 


538  OPERATIONS  ON  THE  ABDOMEN. 

or  fatal  liEeiiiorrhage  from  injur}^  to  large  pelvic  vessels  is  rare.  Very- 
severe  and  even  alarming  haemorrhage  may,  however,  take  place  from 
the  cyst  wall  or  its  interior.  This  is  especially  likel}^  to  happen  when 
the  solid  contents  of  a  pajDillar}'  cyst  are  being  scooped  out  by  the  hand. 
If  the  pedicle  can  be  got  at  readily  and  ligatured,  this  should  be  quicklj^ 
done.  If  not,  the  advice  given  by  Dr.  H.  A.  Kelly  (loc.  supra  cit.,  p.  296) 
should  be  followed.  "  The  only  safe  plan  is  to  control  at  once  the  main 
vessels  going  to  the  tumour  by  applying  arter^^  forceps  to  the  broad 
ligament  at  the  j^elvic  brim  so  as  to  catch  the  ovarian  vessels,  and  one 
or  two  23airs  at  the  uterine  corner  to  catch  the  uterine  vessels." 

(7)  Leaving  in  Instruments. — jE/.f/.,  sponge  or  forceps.  The  fact  that 
this  accident  has  occurred  with  operators  of  the  largest  experience 
should  make  all  careful.  It  is  best  met  by  having  a  sufficient  definite 
number  to  begin  with,  counting  carefully  afterwards,  and  allowing  no 
tearing  of  sponges. 

After-treatment. — The  patient  should  be  kept  on  her  back  for  two 
days  after  the  operation,  and  a  pillow  placed  under  her  knees.  At  the 
end  of  that  time  she  may  be  turned  first  on  to  one  side  then  on  to  the 
other.  If  a  glass  drainage-tube  is  made  use  of,  she  must  be  kept  on 
her  back  till  the  tube  is  removed.  The  most  careful  attention  should 
be  paid  to  the  bedding  under  her,  and  the  nurse  should  see  that  there 
are  no  creases  in  the  mackintosh  or  sheets,  A  few  wrinkles  will  cause 
the  patient  the  most  acute  discomfort. 

The  retching  and  vomiting  that  patients  sulfer  from  after  an 
abdominal  operation  is  considerably  more  than  the  anaesthetic  alone 
will  account  for.  Drugs  should  not  be  employed  to  combat  the 
sickness.  In  fact,  they  will  generally  be  found  to  be  useless.  The 
proper  treatment  of  the  stomach  is  rest  during  the  first  twenty  hours. 
The  only  thing  that  should  be  given  during  this  time  is  hot  water,  and 
of  this  a  tablespoonful  ma}^  be  taken  at  a  time  as  hot  as  can  be  borne 
comfortably.  This  will  be  found  to  be  most  acceptable  to  the  patient, 
reviving  her,  and  often  removing  the  feeling  of  faintness.  Ice  should 
not  be  given  either  for  the  sickness  or  to  allay  thirst.  The  iced  water 
remains  unabsorbed  in  the  stomach,  and  is  sooner  or  later  rejected. 
At  the  end  of  twenty-four  hours  small  quantities  of  nourishment  may 
usually  be  given.  It  is  difficult  to  lay  down  rules  with  regard  to 
quantities.  In  a  straightforward  case  two  drachms  of  milk,  which  has 
been  peptonised  beforehand,  may  be  given  every  half-hour  to  com- 
mence with,  and  the  quantity  increased  to  two  ounces  every  hour  at 
the  end  of  two  days.  Albumen  water,  made  by  dissolving  the  white 
of  an  e^g  in  half  a  pint  of  water,  maj^  be  usefully  given,  mixed  in 
equal  quantities  with  the  milk.  If  vomiting  is  persistent,  enough 
water  should  be  given  to  keep  the  mouth  moist,  and  the  patient  fed 
with  nutrient  enemata  and  suppositories,  given  alternately  every  four 
hours.  In  slighter  cases  of  vomiting  albumen  water  alone  is  often 
well  tolerated. 

The  bowels  should  be  opened  about  the  third  day.  This  is  best 
efiected  b}^  means  of  an  oil  enema  given  on  the  morning  of  the  third 
day,  followed  later  b}^  a  soap  and  water  one,  or  else  two  or  three  grains 
of  calomel  may  be  administered  on  the  evening  of  the  second  day, 
followed  by  a  saline  purge  the  next  morning.  The  unloading  of  the 
bowels  will,   as    a    rule,  make   the    patient    more    comfortable,   relieve 


REMOVAL  OF  TPIE  UTERINE  APPENDAGES.  539 

flatulence  from  which  !^he  may  have  been  sufFering,  and  allow  her  to 
take  more  nomnshment.  The  patient  should  be  allowed  and  encouraged 
to  pass  her  water  naturally  after  the  operation.  If  she  cannot  do  so 
a  catheter  should  be  passed  at  the  end  of  twelve  hours,  every  possible 
precaution  being  taken  to  prevent  infection  of  the  bladder. 

The  routine  use  of  opium  in  any  form  is  to  be  avoided.  On  this 
subject  I  cannot  do  better  than  quote  the  late  Mr.  Greig  Smith's  words : 
"AH  medicines  are,  if  possible,  to  be  avoided,  particularly  opium.  Pain 
I  believe  to  be  not  so  strong  an  indication  for  opium  as  restlessness. 
Sickness  and  tvmpanites  are  predisposed  to,  if  not  often  caused  by 
opium.  One  expects,  after  the  first  dose  has  been  administered,  to  see 
the  patient  wake  up  in  the  morning  with  a  dry  tongue,  increased 
thirst,  and  some  feeling  of  nausea,  which  during  the  day  do  not  pass 
off,  but  culminate  in  restlessness  at  night,  requiring  the  administration 
of  a  second  dose.  We  rarely  see  a  case  treated  throughout  with  a 
perfectly  flat  or  retracted  abdomen  if  opium  has  been  administered. 
When  the  patient  tosses  about  in  bed,  fidgety  and  restless,  without 
any  particular  symptoms  beyond  those  incident  to  a  serious  operation, 
opium  is  undoubtedly  of  great  value." — (Ahdom.  Surg.,  1896,  vol.  1. 
p.  210.) 


REMOVAL     OF    THE     UTERINE    APPENDAGES.* 

Indications.f — Before  giving  these,  I  would  state  that  there  is  no 
operation  in  which  it  is  more  necessary  to  consider  each  case  on  its 
own  bearings,  to  explain  the  object  and  results  with  honourable 
carefulness  to  the  friends  and,  whenever  possible,  to  the  patient  herself, 
and  to  remember  that  this  is  above  all  one  of  those  operations  which 
should  never  be  entertained  if  there  are  any  honest  doubts  as  to  the 
patient's  health  being  really  impaired  beyond  the  aid  of  other  treat- 
ment, and  the  impossibility  of  otherwise  restoring  her  to  usefulness 
in  the  position  of  life  in  which  she  has  been  placed ;  and  that  it  is  an 
operation  which  may  concern  the  happiness  of  another  besides  that  of 

*  This  term  has  been  used  here  for  convenience'  sake,  as  more  comprehensive  than 
•■  oophorectomy,"  &c. 

f  A  paper  read  some  years  ago  at  one  of  our  medical  societies,  and  the  discussion 
thereon,  has  brought  this  matter  prominently  before  the  profession.  I  would  strongly 
advise  my  younger  readers  to  study  carefully  a  very  weighty  letter  in  the  journals 
of  February  7,  1891,  bearing  the  weU-known  signatures  of  Sir  John  Williams  and  Dr. 
Champneys.  Every  sentence  will  weU  repay  perusal.  I  quote  a  few :  "  Perimetritis 
is  probably  the  very  commonest  of  all  the  serious  diseases  of  women.  It  is  also 
perfectly  certain  that  the  great  majority  of  cases  get  quite  well  without  any  operation. 
We  are  far  from  denying  that  exceptional  cases  call  for  surgical  procedures,  or  that 
cases  of  prolonged  suppuration  in  the  pelvis  are  properly  treated  by  the  application 
to  them  of  ordinary  surgical  principles.  But  this  wholesale  resort  to  a  mutilating 
operation,  advocated  by  several  speakers  at  these  discussions,  calls  for  serious  con- 
sideration by  the  profession.  ...  A  plea  for  patience  is  to  be  found  in  the  declaration 
of  the  operators  that  the  f uU  benefits  of  the  operation  are  not  felt  for  months  or  years 
after.  If  the  operator  would  exercise  this  patience  before  the  operation,  there  might 
be  less  need  for  its  exercise  by  the  patient  after  the  operation." 


540  OPERATIONS  ON  THE  ABDOMEN. 

the  patient.  Due  weight  must  be  given  to  the  large  part  played  hy 
neuroses  in  this  matter,  and  to  the  fact  that  till  we  have  carefully 
published  cases  in  which  the  results  have  been  submitted  to  the  onl}' 
true  test,  that  of  time,  we  shall  not  be  in  a  position  to  decide  how  far 
the  after-condition  of  a  great  number  of  the  patients  who  have  been 
submitted  to  this  operation,  is  one  of  improvement.  Finally,  it  is 
always  to  be  remembered  that  it  is  an  operation  which  lias  been 
greatly  misused. 

The  following  is  a  limited  list  of  indications  for  removal  of  the 
uterine  appendages  : 

(i)  Diseases  of  the  Fallopian  Tubes  and  Ovaries. — Of  these,  the 
inflammatory  affections  concern  us  chiefl}',  in  the  form  of  salpingitis, 
pyo-,  hydro-,  or  hsemato-salpinx,  ovaritis,  ovarian  abscess,  or  tubo- 
ovarian  abscess.  Other  diseases  include  ovarian  new  growths  which 
have  been  considered  under  the  heading  of  ovariotomy  and  tumours 
of  the  Fallopian  tube,  which  do  not  call  for  separate  treatment.  It  is 
not  easy  to  make  rules  for  guidance  that  will  apply  to  all  cases  of 
inflammation  of  the  appendages.  Every  case  demands  careful  con- 
sideration on  its  own  merits.  The  broad  lines  of  treatment  may. 
nevertheless,  be  indicated ;  they  are  not  unlike  those  that  guide 
us  in  the  treatment  of  appendicitis.  In  the  following  indications. 
Mr.  Cullingworth  (Syst.  of  Gyn..  Allbutt  and  Playfair.  1896,  p.  514)  is 
closely  followed : 

(a)  Operation  during  Acute  Attacli. — It  is  not  often  that  surgical 
interference  is  called  for  during  an  acute  attack.  The  difficult}',  and 
more  especially  the  danger,  of  the  operation  is  increased  during  this 
stage.  Moreover,  the  advisability  of  treating  the  inflammation,  when 
acute,  by  rest  is  shown  by  the  generally  good  results  obtained.  Even 
if  pus  is  suspected,  the  surgeon  should  not  be  in  too  great  a  hurr}'  to 
operate.  One  well-defined  indication  for  interference  during  the  acute 
attack  has  been  laid  stress  on  by  Mr.  Cullingworth,  and  that  is  the 
accumulation  of  fluid,  more  especially  if  it  be  purulent,  in  sufficient 
amount  to  distend  Douglas's  pouch  and  encroach  on  the  vagina  and 
rectum.  Here,  "  there  can  be  no  hesitation  as  to  the  propriety  of 
making  an  opening  through  the  vaginal  roof.  Such  timely  interference 
will  not  only  afford  immediate  relief  to  the  more  urgent  symptoms,  but 
will  prevent  the  bursting  of  an  abscess  into  the  rectum." 

(A)  Becurrent  Attacks. — A  history  of  recurrent  attacks  of  peritonitis 
almost  invariably  means  the  presence  of  pus.  If,  with  this  history,  the 
patient  has  a  swelling  which  has  "  attained  such  dimensions  as  to  make 
it  fairly  certain  that  in  the  midst  of  it  there  is  either  an  occluded  and 
distended  Falloj^ian  tube,  or  an  ovary  enlarged  by  cystic  growth,  the 
indications  for  the  removal  of  the  disease  are  perfectly  clear." 

(c)  The  class  of  life  to  which  the  patient  belongs  must  be  considered. 
A  woman  who  has  to  earn  her  living  cannot  afford  to  submit  to  pro- 
longed treatment  by  rest,  if  by  operation  she  can  secure  a  more  i-apid 
recovery. 

(d)  Persistence  of  Symptoms  after  Acute  Attacli. — In  most  cases,  with 
rest  and  appropriate  treatment,  the  inflammatory  mass  subsides,  the 
pain  disappears,  and  the  patient  is  restored  to  health.  It  occasionally 
happens,  however,  that  the  symptoms  persist,  and  unless  some  relief  is 
affbi-ded  the  patient,  there  is  danger  that  she  will  drift  into  a  condition 


REMOVAL  OF  THE  UTERINE  APPENDAGES.  54I 

of  chronic  invalidism,  and  become  unlit  for  any  of  the  ordinary  vocations 
of  life.  These  cases  present  many  points  of  difficulty,  and  the  treatment 
to  be  adopted  must  depend  upon  the  existing  condition.  Should  it  be 
found  that  the  inflammatory  mass,  instead  of  subsiding,  persists,  the 
advisability-  of  operating  will  have  to  be  considered.  But  before 
resorting  to  an  operation  that  involves  removal  of  tubes  and  ovaries, 
the  question  of  how  long  expectant  treatment  should  be  persevered 
in,  presents  itself.  The  class  of  life  of  the  patient,  as  a  factor  to  be 
taken  into  consideration,  has  already  been  mentioned.  Mr.  Herman, 
in  answering  this  question,  gives  the  following  practical  advice  : — 

'•Most  cases  will  get  well  within  two  months;  but  I  have  seen 
expectant  treatment  followed  out  for  two  months  without  relief,  and 
then  the  patient  has  begun  to  improve.  I  therefore  think  that  three 
months  is  the  minimum  which  in  doubtful  cases  should  be  considered 
a.  fair  trial  of  expectant  treatment.  This  is  only  a  statement  as  to 
most  cases,  not  a  rule  to  be  applied  to  every  case  "  (Disease^?  of  Women, 
p,  240).  On  the  other  hand,  the  inflammatory  mass  may  have  sub- 
sided as  the  result  of  treatment,  but  pain  persists,  and  we  find  on 
examination  that  the  pelvic  organs  are  displaced  and  fixed  by  adhesions. 
Under  these  circumstances  greater  patience  must  be  exercised,  and  the 
necessity  for  removal  of  the  appendages  most  carefully  considered 
before  such  a  method  of  treatment  is  adopted.  In  some  of  these  cases 
a  conservative  operation  may  be  advantageously  practised,  and  proceed- 
ings limited  to  thorough  freeing  of  adhesions  and  fixation  of  the  organs 
in  better  position.  And,  lastly,  we  meet  with  cases  in  which  the  pain 
does  not  appear  to  have  sufficient  physical  basis  to  justify  us  in  re- 
commending any  operation. 

(2)  Fibro-myoma  of  the  Uterus. — Oophorectomy  no  longer  occupies 
the  position  it  did  in  the  treatment  of  fibroids ;  its  place  has  been  taken 
bj'  hysterectomy,  and  there  are  several  reasons  for  this.  The  removal 
of  the  ovaries  is  not  followed  by  uniformly  satisfactory  results,  though, 
as  Mr.  Doran  points  out,  we  can  never  feel  sure,  in  cases  of  failure, 
that  all  the  ovarian  tissue  has  been  removed.  As,  however,  some 
fibroids  may  go  on  growing  and  may  recj[uire  hysterectomy  after  the 
menopause,  it  is  only  natural  to  suppose  that  a  similar  result  may 
follow  the  induction  of  an  artificial  menopause.  Another  disadvantage 
of  oophorectomy  is  that  the  patient  is  left  with  a  tumour  which, 
diminishing  in  size  slowly,  may  have  time  to  exercise  injurious  pressure 
on  neighbouring  organs.  It  seems  reasonable,  moreover,  to  suppose 
that  a  patient  with  both  her  ovaries,  and  without  a  uterus,  is  in  a 
better  position  than  one  possessing  a  uterus  enlarged  by  fibroids  and 
no  ovaries  ;  and  such  evidence  as  we  possess  at  present  points  to  the 
justice  of  this  conclusion. 

Removal  of  the  ovaries  is  by  no  means  an  easy  operation  in  all  cases. 
When  the  tumour  is  large  the  operator  will  find  it  often  difficult,  and 
occasionally  impossible,  to  remove  the  ovaries,  more  especially  when 
the  tumour  grows  into  the  broad  ligament. 

There  are  three  conditions  which,  considered  separately  or  together, 
may  influence  us  in  the  choice  of  oophorectomy  rather  than  hyste- 
rectomy. The  most  important  is  the  general  condition  of  the  patient. 
If  tliis  is  such  as  to  militate  against  a  prolonged  operation,  oophorec- 
tovay  should  be  chosen,  provided  that  the  ovaries  can  be  readily  got 


542  OPERATIONS  ON  THE  ABDOMEN. 

at  and  completely  removed.  When,  from  the  nature  and  situation  of 
the  tumour,  it  is  thought  that  the  risks  of  removal  are  unusually  great, 
removal  of  the  ovaries  may  be  chosen  in  preference  to  that  of  the 
uterus.  There  would  be  less  hesitation  in  removing  the  ovaries  if 
the  patient  were  near  the  menopause,  though  it  should  be  remembered 
that  this  is  often  delayed  till  after  fifty  years  of  age.  Age  alone  does  not 
often  determine  the  choice  of  operation,  but,  taken  in  conjunction  with 
the  condition  of  the  patient  or  the  character  of  the  tumour,  it  is  a  factor 
to  be  borne  in  mind.  In  those  cases  in  which  the  tumour  gives  trouble 
after  the  menopause,  and  an  operation  is  called  for,  removal  of  the 
ovaries  would,  naturally,  not  be  chosen. 

(3)  Dysmenorrhoea  and  various  Neuroses. — Oophorectomy  for 
dysmenorrhoea  has  been  attended  by  such  disappointing  results  that 
the  greatest  hesitation  should  be  adopted  in  suggesting  its  perform- 
ance or  carrying  it  out.  Practically  the  only  cases  in  which  removal 
of  the  ovaries  for  severe  menstrual  pain  should  be  entertained  are  those 
in  which  the  pain  may  reasonably  be  ascribed  to  some  lesion  affecting 
these  organs.  In  some  of  these  cases  the  ovaries  are  the  seat  of 
chronic  ovaritis,  occasionally  accompanied  by  definite  inflammation 
of  the  tubes.  When  with  such  a  condition  the  patient  has  intolerable 
monthly  pain,  which  has  resisted  all  attempts  at  treatment  by  rest  and 
drugs,  and  when,  as  Dr.  Griffiths  points  out  (St/st.  Gijn.,  Allbutt  and 
Playfair,  p.  864),  the  suffering  is  not  out  of  all  proportion  to  the 
ascertained  lesions,  removal  of  the  inflamed  ovaries  will  have  to  be 
considered.  Whilst  this  operation  may  relieve  the  local  sjmiptoms,  the 
general  nervous  symptoms  from  which  these  patients  suffer  very  often 
persist,  or  become  intensified,  and  ma}'  prove  as  grave  a  source  of 
trouble  as  the  original  pain.  A  very  necessaiy  note  of  warning  has 
been  sounded  by  Mr.  Bland  Sutton,  Dr.  Howard  Kelly,  and  others,  with 
regard  to  the  diagnosis  of  oophoi'itis.  The  ovary  may  normally  contain 
large  Graafian  follicles,  and  the  presence  of  these  does  not  constitute 
oophoritis.  A  cystic  ovarj'.  the  result  of  inflammation,  is  considerably 
larger  than  normal,  with  a  thickened  tunica  albuginea,  and  a  stroma 
that  is  more  fibrous  and  denser  than  normal.  With  regard  to  other 
neuroses,  such  as  hysteria,  epilepsy,  and  insanity,  experience  has  shown 
us  that  the  removal  of  the  ovaries  for  this  condition  is  not  justified 
by  the  results  obtained.  On  this  subject  Mr.  Bland  Sutton's  remarks 
are  worth  careful  attention  : 

"  The  removal  of  the  ovaries  and  tubes  has  been  recommended  and 
practised  for  the  relief  of  such  conditions  as  ( i )  Epilepsy  and  insanity  ; 
(2)  Dysmenorrhoea  ;  (3)  Ovarian  neuralgia.  In  this  group  the  pro- 
cedure has  not  been  followed  by  encouraging  results  ;  indeed,  they 
are  so  unsatisfactory,  that  those  who  have  had  the  greatest  experience 
in  this  class  of  surgery  are  almost  unanimous  in  condemning  the 
operation,  save  under  very  exceptional  conditions :  even  then  the 
operator  should  safeguard  himself  by  seeking  confirmatory  opinion. 
The  chief  objections  are  summarised  in  the  following  clauses  :  (i)  In 
a  very  large  proportion  of  cases  the  removal  of  the  ovaries  and  tubes 
fails  to  relieve  the  patient.  (2)  In  many  cases  the  operation  aggravates 
the  symptoms.     ^^J  Many  cases,  reported  a  few  weeks  or  months  after 

the  operation,  have   subsequently  relapsed In   man}-  instances 

where  oophorectomy  has  been  carried  out  for  relief  of  pain,  unaccom- 


REMOVAL  OF  THE   UTERINE  APPENDAGES.  543 

panied  by  objective  signs  in  the  pelvic  viscera,  the  operators  have 
pointed  out,  in  justification  of  the  interference,  that  the  ovaries  were 

cystic Such  men  ....  when  they  excise  an   ovary  for  pain, 

cut  into  the  organ,  and,  finding  ripe  follicles,  describe  it  as  a  cystic 
ovary.  Every  normal  ovary  is  cystic,  hence  an  excuse  is  readily 
found."  Even  when  some  definite  lesion  exists  the  results  have  not 
proved  satisfactory.  Writing  of  epilepsy,  Dr.  Weir  Mitchell  (quoted 
by  Dr.  H.  Kelly,  loc.  cit.,  vol.  ii.  p.  194)  says  :  "  In  no  case  seen  by 
me  had  ablation  of  the  ovaries  and  termination  of  menstruation  cured 
epilepsy.  I  have  never  sanctioned  such  operations  where  the  appendages 
were  sound.  I  have  agreed  thrice  to  these  operations  in  epilepsy 
with  such  pelvic  disease  as  of  itself  would  justif}^  oophorectomy.  In 
all  three,  after  some  delay,  the  fits  returned,  and  were  in  no  way 
permanently  aided." 

(4)  Osteomalacia. — The  removal  of  the  ovaries  in  the  treatment  of  this 
disease  has  been  performed  a  number  of  times  since  it  was  suggested 
by  Professor  Fehling,  of  Bale,  in  1887,  and  appears  to  have  met  with 
signal  success,  the  course  of  the  disease  being  arrested  and  the  patients 
restored  to  active  life  (Bland  Sutton,  loc.  supra  cit.,  p.  384). 

(5)  Inoperable  Cancer  of  the  Breast. — The  question  of  oopho- 
rectomy of  this  condition  has  already  been  considered  in  Vol.  i.  p.  683. 

The  Operation. 

(i)  When  Appendages  are  not  Inflamed,  or  Adherent. — The  pre- 
paration of  the  patient,  operating-room,  &c.,  is  similar  to  that  already 
described  for  ovariotomy.  An  incision  of  about  two  inches  is  made 
in  the  median  line,  and  carried  down  to  within  an  inch  of  the  pubes. 
The  different  structures  of  the  abdominal  wall  are  divided  until  the 
peritonasum  is  reached.  This  is  then  picked  up  by  a  pair  of  forceps, 
and,  care  being  taken  that  intestine  is  not  included  in  the  grasp  of 
the  forceps,  is  divided  horizontally.  The  peritoneum  is  then  incised 
for  the  length  of  the  incision  on  two  fingers  used  as  a  director.  Two 
fingers  are  now  inserted  into  the  abdominal  cavity  and  seek  the  fundus 
uteri.  From  this  starting-point  they  are  passed  along  one  or  other 
broad  ligament,  and  seize  the  corresponding  Fallopian  tube  and  ovaiy, 
which  are  then  drawn  out  of  the  wound.  With  a  blunt  pedicle  needle 
a  double  ligature  is  passed  through  the  broad  ligament,  and  the  loop  of 
the  ligature  being  divided,  the  two  strands  are  interlocked.  One 
ligature  is  carried  round  the  tube  close  to  its  uterine  attachment  and 
tied  firmly,  and  the  other  one  is  tied  over  the  free  edge  of  the  broad 
ligament.  Whilst  the  ligatures  are  being  tightened  the  traction  on 
the  appendages  should  be  relaxed.  A  pair  of  Spencer  Wells's  forceps 
are  then  applied  just  beyond  the  ligature,  and  the  ovary  and  tube 
cut  away.  The  application  of  the  forceps  enables  the  operator  to 
carefully  inspect  the  stump  for  hsemorrhage  before  allowing  it  to  fall 
back  into  the  abdominal  cavity.  The  other  side  having  been  treated 
in  a  similar  way  the  abdominal  wound  is  sutured.  It  is  not  necessary 
to  wash  out  the  peritoneal  cavity  or  to  drain. 

It  has  been  objected  to  this  mode  of  tying  the  broad  ligament  that  it 
puts  tension  on  it,  and  drags  together  its  pelvic  and  uterine  ends,  so 
leading  to  the  risk  of  the  ligature  slipping,  with  consequent  hemorrhage. 
Dr.  H.  Kelly  (Oper.  Gijn.,  vol.  ii.  p.  198)  therefore  recommends  that  the 
uterine  and  ovarian  vessels  should  be  tied  separately.     "The  first  liga- 


544  OPERATIONS  OX  THE  ABDOMEX. 

ture  includes  the  ovarian  veins  and  artery,  and  is  passed  through  the 
clear  space  in  the  broad  ligament  and  tied  near  the  pelvic  brim  over  the 
top  of  the  infundibulo-pelvic  ligament,  well  beyond  the  fimbriated  end 
of  the  tube.  A  second  ligature  is  applied  to  the  utero-ovarian  ligament 
posteriorly.  A  third  ligature  is  passed  over  the  top  of  the  broad  liga- 
ment at  the  cornu  uteri,  embracing  the  uterine  vessels  which  are  visible 
and  the  isthmus  of  the  tube."  Any  bleeding  points  in  the  cut  edge  of 
the  broad  ligament  are  seized  Avith  forceps  and  tied.  A  longer  incision 
will  be  required  when  oophorectomy  is  performed  for  fibroids.  There 
may  be  considerable  difficulty  in  removing  the  appendages,  and  in  those 
cases  in  which  the  fibroid  grows  into  the  broad  ligament,  spreading 
out  the  mesovarium,  it  may  be  impossible  to  apply  a  ligature  between 
the  ovary  and  tumour. 

(2)  Removal  of  Appendages  when  they  are  Inflamed  and 
Adherent. 

This  is  an  operation  that  may  present  very  grave  difficulties  in  its 
carrying  out.  There  are  two  routes  by  which  the  removal  of  the  appen- 
dages may  be  effected — the  abdominal  and  the  vaginal.  Of  these  the 
former,  besides  being  the  older,  is  the  preferable  form  of  operation. 
The  latter  is  only  suitable  to  those  cases  in  which  the  adhesions  are  not 
dense  and  in  which  extensive  fixation  to  the  abdominal  viscera  does  not 
occur.  And  as  it  is  extremely  difficult  to  estimate  beforehand  the 
character  and  the  extent  of  the  adhesions,  the  operator  had  better  con- 
fine himself  to  the  abdominal  route  rather  than  run  the  risk  of  having 
to  open  the  abdomen  to  complete  an  operation  that  was  found  im- 
practicable from  the  vagina. 

In  dealing  with  the  adhesions  the  late  Mr.  Lawson  Tait  considered  it 
best  to  depend  entirely  upon  the  sense  of  touch;  and  he.  has  been 
followed  in  this  teaching  by  many  surgeons.  The  operation  is  carried 
out  through  a  comparatively  small  abdominal  incision,  and  the  sense  of 
touch  is  relied  on  entirely  in  guarding  the  oiDerator  from  the  infliction 
of  injury  whilst  separating  the  tubes  from  adherent  structures.  The 
operation  will,  however,  be  much  facilitated  for  those  with,  less  experi- 
ence, by  bringing  into  play  not  only  the  sense  of  touch  but  that  of 
sight.  For  this  purpose  the  patient  should  be  placed  in  the  Trendelen- 
berg  position  as  affording  a  better  view  of  the  pelvic  viscera. 

Abdominal  Incision. — The  patient  being  in  this  position,  an  incision 
about  four  inches  long  is  made  in  the  median  line  and  carried  well 
down  to  the  pubes.  The  steps  of  this  part  of  the  operation  are  similar 
to  those  described  in  ovariotomy.  On  reaching  the  peritonaeum  care 
must  be  taken  in  opening  the  abdominal  cavity,  and  the  operator  should 
bear  in  mind  the  possibility  of  adhesions  existing  between  the  omentum 
or  intestines  and  the  wall.  The  peritonteum  is  picked  up  and  rolled 
between  the  finger  and  thumb,  and  the  absence  of  adhesions  being  noted, 
is  incised,  when  the  viscera  at  once  falls  away  from  the  parietes. 
Omentum  or  intestines  found  adherent  to  the  abdominal  wall  must 
be  carefully  separated  by  means  of  the  fingers. 

Adhesions. — The  condition  existing  should  then  be  carefully  ascer- 
tained, and  the  first  thing  likely  to  demand  attention  is  adherent 
omentum.  This  is  frequently  found  covering  in  and  adherent  to  the 
pelvic  viscera,  and  it  may  also  be  much  thickened  b}'  inflammation.  It 
should  be  freed  carefully  from  its  attachments  to  the  pelvic  organs  with 


liEMUN'AL   UF  THE   UTEiilXE  AiTEXDAGES.  545 

the  fingers,  care  being  taken  not  to  iujui-e  intestines  or  bladder.  Any 
bleeding  points  should  be  at  once  secured.  If  much  difficulty  exists  in 
freeing  the  omentum  or  in  determining  its  exact  relationship  to  other 
parts,  it  had  better  be  ligatured  and  divided,  the  lower  attached  portion 
being  dealt  -with  later.  In  any  case  it  is  better  to  ligature  and  remove 
portions  of  omentum  much  thickened  by  inflammatory  changes.  If 
intestines  are  adherent  they  must  be  separated  A^th  great  care,  and  it 
is  in  this  stage  of  the  operation  that  the  Trendelenberg  posture  will  be 
found  of  great  assistance.  The  bowel,  more  especially  after  the  separa- 
tion of  firm  adhesions,  should  be  carefully  inspected,  and  any  damage 
to  the  walls  at  once  repaired.  All  adhesions  existing  between  the 
intestines  and  omentum  on  the  one  hand,  and  the  pelvic  viscera  on  the 
other,  ha\'ing  been  freed,  the  abdominal  organs  are  pushed  back  towards 
the  diaphragm  and  maintained  in  position  with  a  large  flat  sponge  or 
gauze  pad.  There  may  be  some  difiiculty  in  doing  so  if  the  abdominal 
walls  are  rigid  and  the  patient  not  fully  under  the  anaesthetic.  A  little 
patience,  however,  will,  as  a  rule,  allow  of  the  viscera  being  pushed  up 
out  of  the  way.  so  as  to  enable  the  operator  to  obtain  a  view  of  the 
pelvic  contents. 

Eiiadeatioii  of  AyiieitJuges. — The  operator  is  now  in  a  position  to  set 
about  freeing  the  adherent  appendages.  As  far  as  is  possible  the 
condition  present  is  ascertained  by  sense  of  sight  as  well  as  that  of 
touch,  the  position  of  the  uterus  located,  and  the  extent  and  fixity 
of  the  mass,  formed  by  one  or  both  appendages,  noted.  The  matted 
tube  and  ovary  forms  a  tumour  lying  to  the  back  of  the  uterus  and 
broad  ligament  in  the  lateral  fossa  or  Douglass  pouch,  and  the  broad 
ligament  is  drawn  over  the  front  of  the  mass.  The  first  step  in  enuclea- 
tion is  the  separation  of  the  mass  from  its  posterior  connections  and 
from  the  opposite  appendages,  if  inflamed.  To  efiect  this,  the  hand, 
with  the  palmar  surface  forward,  is  passed  down  in  the  hollow  of  the 
sacrum  behind  the  mass,  carefully  separating  with  the  tips  of  the 
fingers  the  adhesions  that  fix  it  in  thi^  situation.  Mr.  Cullingworth 
considers  that  at  this  stage  it  is  often  desirable  for  an  assistant  to  pass 
a  forefinger  into  the  rectum  to  serve  as  a  guide.  Working  down  in  this 
way  the  lower  part  of  the  mass  is  reached.  The  next  step  is  its 
separation  from  the  back  of  the  broad  ligament  to  which  it  is  fixed, 
and  which  efiectually  prevents  the  tube  being  drawn  up  into  the  wound. 
Enucleation  is  consequently  continued  from  below  upwards  with  the  tips 
of  the  fingers  inserted  between  the  mass  and  the  back  of  the  broad 
ligament.     In  this  way  it  is  gradually  freed  from  all  its  connections. 

Removal  of  Diseased  Parts. — The  affected  parts  are  now  drawn  ^\•ell 
up  through  the  abdominal  incision,  and  a  suitable  point  in  the  broad 
ligament  chosen  for  transfixion.  A  blunt  pedicle  needle  with  a  double 
ligatui-e  is  then  passed  through  the  broad  ligament,  and  the  loop 
di%aded.  The  two  strands  are  interlocked  where  they  pass  through  the 
broad  ligament  to  prevent  the  tearing  apart  of  this  structure,  when 
they  are  tied.  Each  ligature  is  then  tied  separately',  one  round  the 
Fallopian  tube  close  to  the  uterine  cornu,  the  other  round  the  free 
upper  border  of  the  broad  ligament,  and.  a  pair  of  forceps  being  applied 
to  the  tube  just  beyond  the  ligature,  the  diseased  parts  are  cut  away. 
Or  the  method  of  Dr.  H.  Kelly  described  above,  which  presents  some 
advantages,  may  be  employed. 

VOL.  II.  '  35 


546  OPERATIONS  OX  THE  ABDOMEN. 

The  cut  end  of  the  tube  held  in  the  forceps  is  next  brought  into 
view  and  carefully  wiped  with  i-iooo  perchloride  of  mercury  solution, 
or  else  cauterised  with  Paquelin's  cautery  to  obviate  the  risk  of  sub- 
sequent infection  from  the  cut  end.  Before  allowing  the  stump  to 
fall  back  into  the  pelvis,  the  parts  are  carefully  examined  for  bleeding 
points,  which  should  be  seized  with  forceps  or  else  under-run.  Care 
should  be  exercised  in  the  application  of  forceps  in  the  pelvis  lest  a 
portion  of  the  rectal  wall  be  nipped,  and  its  vitality  so  affected  that 
it  subsequently  sloughs. 

Treatment  of  Tube  when  Distended. — If  the  tube  is  found  to  be  dis- 
tended with  pus  or  other  fluid,  it  is  better,  if  possible,  to  remove  it 
without  previously  emptying  it.  This  is  recommended  on  account 
of  the  greater  ease  of  dealing  with  a  distended  tube  than  one  empty 
and  collapsed.  Greater  care  must,  however,  be  exercised  in  the 
separation  of  adhesions,  and  the  parts  packed  round  with  gauze  or 
sponges  to  j^revent,  as  far  as  possible,  the  spread  of  infective  material 
if  the  tube  ruptures,  as  it  may  very  possibly"  do  in  the  course  of 
manipulation.  Should  rupture  occur  the  fluid  must  be  removed  as 
rapidly  as  possible,  all  infected  sponges  and  swabs  taken  away,  and 
the  parts  thoroughly  cleansed. 

Hcemorrhage. — Oozing  from  large  raw  surfaces  is  sometimes  free,  but 
generally  yields  to  pressure  exercised  by  sponges  in  the  course  of  the 
operation.  Should  it  still  persist,  and  no  obvious  bleeding  point  be 
visible  at  the  end  of  the  operation,  the  pelvis  should  be  packed  firmly 
with  strips  of  gauze,  the  ends  of  which  are  left  out  of  the  lower  parts 
of  the  abdominal  incision.  The  strips  should  be  removed  at  the  end 
of  twenty-four  hours.  This  is  preferable  to  the  emplo3mient  of  the 
cautery  or  perchloride  of  iron.  Bleeding  to  such  an  extent  as  to  be 
alarming  is,  when  it  occurs,  most  likeh'  to  be  due  to  injur}^  to  the 
broad  ligament  and  its  vessels  in  the  separation  of  the  tube  from  its 
posterior  surface.  A  search  may  be  made  for  the  vessel  with  the 
patient's  pelvis  raised  and  a  good  light.  This,  however,  will  be  found 
to  be  most  difficult,  and  will  very  likely  be  unsuccessful.  The  advice 
given  in  Dr.  Baldy's  Gi/ncBcologj/  (1894,  p.  509)  to  secure  the  ovarian 
and  terminal  branches  of  the  uterine  artery  by  passing  a  threaded 
needle  through  the  broad  ligament  close  to  the  pelvic  wall,  and  a 
second  one  through  the  broad  ligament  near  the  uterine  cornu, 
appears  to  be  worthy  of  trial  under  these  circumstances. 

Drainryje  will  be  called  for  more  often  in  the  case  of  pelvic  in- 
flammation than  of  ovarian  tumours.  The  following  may  be  regarded 
as  indications  for  its  employment : 

(i)  When  large  raw  surfaces  have  been  left  after  the  separation  of 
extensive  adhesions,  and  it  is  thought  that  the  amount  of  exudation 
likely  to  be  poured  out  is  more  than  the  damaged  peritongeum  can 
deal  with. 

(2)  When,  in  the  course  of  removal,  a  pyo-salpinx,  or  abscess-cavity, 
has  ruptured  and  soiled  surrounding  parts. 

(3)  When  the  bowel  has  been  injured  in  the  course  of  the  operation. 
Damage  to  the  small  intestine  can  generally  be  repaired  without  risk 
of  subsequent  leakage.  Injury  to  the  rectum  cannot  be  so  readily 
dealt  with,  and  it  may  be  impossible  for  the  operator  to  gain  such 
access  to  the  damaged  parts  as  will  enable  him  to  repair  the  lesion. 


REMOVAL  OF  THE  UTERINE  APPENDAGES.  547 

To  prevent  general  infection  of  the  peritonasal  cavity,  as  the  result 
of  leakage  from  the  bowel,  he  will  have  to  depend  on  careful  gauze 
packing. 

(4)  When  the  operation  is  incomplete.  Firmness  of  adhesions  and 
danger  of  injury  to  viscera  will  sometimes  lead  the  surgeon  to  leave 
his  operation  unfinished,  rather  than  subject  his  patient  to  unusual 
risk.  He  has  probably  exposed,  in  the  course  of  his  manipulations, 
infected  areas,  such  as  a  pyo-salpinx  or  a  pelvic  abscess.  Under  these 
circumstances  he  will  remove  such  diseased  structures  as  is  found  possi- 
ble, and  provide  free  drainage  by  means  of  gauze  strips  for  the  infected 
parts  left  behind. 

Conservative  Surgery. — By  this  tenn  is  meant  the  preservation  of 
such  organs  or  parts  of  organs  as  are  not  diseased  or  not  beyond  the 
power  of  recovery.  This,  which  is  the  general  principle  underlying 
all  true  surger}^,  receives  special  significance  in  its  application  to  the 
pelvic  organs,  on  account  of  the  importance  of  the  latter  in  securing 
the  happiness  and  well-being  of  the  individual.  This  applies  more 
especially  to  the  ovaries,  which  are  not  only  essential  to  the  functions 
of  menstruation  and  child-bearing,  but  which  exercise — probably  by 
means  of  some  internal  secretion — a  wide  influence  over  nutritive  pro- 
cesses in  general.  That  ever}?-  effort  should  be  made  to  preserve  a 
portion  at  least  of  one  of  these  organs  is  not  disputed  at  the  present 
time ;  the  only  question  is  how  far  one  is  justified  by  one's  attempts 
at  conservatism  in  subjecting  the  patient  to  increased  risks  of  recur- 
I'ence  of  disease  and  further  operation. 

An  important  step  was  made  in  conservative  surgery  when  it  was 
recognised  that  disease  limited  to  the  appendages  of  one  side  did 
not  necessarily  mean  the  removal  of  the  organs  on  both.  A  further 
advance  was  marked  by  the  recognition  that  certain  conditions,  which 
at  one  time  were  thought  to  be  pathological,  were  not  diseases  at  all. 

The  cystic  ovary  is  a  case  in  point.  Though  a  definite  pathological 
condition  does  exist  in  which  the  ovary  is  the  seat  of  numerous  small 
cysts,  the  mere  presence  of  these  does  not  necessarily  constitute  an 
abnormal  state  of  the  organ,  nor  do  they  justify  its  removal. 

A  further  reason  advanced  for  the  practice  of  conservatism  lies  in 
the  fact  that  portions  of  organs  left  behind  are  capable  of  performing 
the  functions  of  the  entire  organ.  It  has  been  shown  clinically  that 
the  stump  of  an  amputated  tube  may  convey  an  ovum  to  the  uterus, 
which  will  then  pass  through  the  developmental  changes  of  normal 
pregnancy  (B.  F.  Baer,  Ann.  of  Gyn.  and  Fed.,  Jan.  1894). 

Dr.  Kelly  (loc.  cit.,  p.  188)  has  recorded  a  case  in  which  pregnancy 
followed  an  operation  involving  the  removal  of  one  tube  and  the  oppo- 
site ovary,  and  where  the  transmission  of  the  ovum  was  effected  by 
the  tube  on  the  side  opposite  to  that  of  the  ovary.  Similar  cases 
have  been  recorded  in  which  pregnancy  has  followed  operations  involv- 
ing partial  removal  of  the  appendages.  Whilst  such  an  occurrence 
may  not  be  very  common,  the  mere  fact  that  it  can  occur  constitutes 
a  farther  reason  for  exercising  such  conservatism  as  is  possible  in 
dealing  Avitli  the  pelvic  organs. 

The  capacity  for  repair  shown  by  inflamed  pelvic  organs  and  the 
powers  of  absorption  of  the  peritonasal  sac  in  the  case  of  large  inflam- 
matory exudates,  is  a  well-established  fact.     A  similar  course  of  events 


548  OPERATIONS  UN  THE  ABDOMEN. 

is  known  to  all  surgeons  in  the  case  of  the  vermifoi'm  appendix.  This 
power  of  regeneration  is  a  point  telling  in  two  ways  ;  for  whilst  it  will 
encourage  the  operator  to  sacrifice  as  little  as  possible  of  the  organs  he 
is  dealing  with,  it  is  also  an  argument  in  favour  of  rest  and  expectant 
treatment. 

There  are  certain  conditions  other  than  disease  of  the  tubes  and 
ovaries  demanding  operation  in  which  there  can  be  no  doubt  as  to 
the  advisability  of  leaving  the  ovaries  or  as  much  of  them  as  can  be 
safely  preserved.  Hysterectomy  for  fibroids  is  a  case  in  point,  where  one 
or  both  ovaries  should  be  left  when  possible.  A  further  example  is 
seen  in  parovarian  cysts,  which  may  be  shelled  out  sometimes  from  the 
broad  ligament  without  sacrificing  tube  or  ovary. 

When  we  come  to  disease  of  the  ovary  itself,  it  is  especially  in  non- 
inflammatory affections  that  an  attempt  may  be  made  to  save  a  portion 
of  the  organ.  Such  conditions  as  cysts  due  to  enlargement  of  Graafian 
follicles  or  corpora  lutea  may  be  dealt  with  on  this  principle — the  cyst 
being  shelled  out  or  a  wedge-shaped  portion  of  the  ovary  being  removed. 
In  the  case  of  dermoids  and  the  cystomata  the  ovarian  tissue  is,  as  a  rule, 
so  involved  that  an  attempt  to  save  a  part  of  it  will  not  often  be  found 
possible.  Even  when,  as  occasionally  happens,  some  of  the  ovarian 
tissue  remains  unaffected,  the  advisability  of  trying  to  preserve  it  is 
open  to  question  on  account  of  the  risk  of  leaving  behind  sufiicient  of 
the  tumour  to  lead  to  a  recurrence.  Nor  does  it  seem  improbable  that 
the  remaining  portion  of  ovary  is  liable  to  a  similar  cystic  change. 
The  chief  justification  for  saving  a  part  of  the  organ  would  be  in  the 
fact  that  the  opposite  ovary  either  required  removal  or  had  alreadj^ 
been  removed. 

It  is  in  dealing  with  inflammatory  conditions  of  the  appendages  that 
the  widest  difference  of  opinion  with  regard  to  conservatism  exists.  It 
was  the  practice  at  one  time,  if  the  appendages  on  one  side  were  diseased, 
to  remove  those  on  the  other  side,  even  if  found  healthy.  This  was  done 
more  especially  in  those  cases  in  which  the  tubes  were  the  seat  of  sup- 
puration. The  late  Mr.  Greig  Smith  (8yst.  ofGyn.,  Allbutt  and  Playfair, 
p.  910)  said:  "The  removal  of  the  appendages  on  one  side  only  for 
suppurative  disease  was  tried  by  Tait,  but  given  up  on  account  of  the 
large  number  of  recurrences  or  relapses.  Other  surgeons  have  had 
similar  experiences ;  and  the  i^ule  in  all  cases  of  suppurative  diseases  of 
the  appendages  now  is  that  if  one  set  is  removed  so  also  should  be  the 
other." 

In  spite  of  the  risks  of  recurrence,  modern  opinion  inclines  strongly 
to  the  preservation  of  healthy  appendages,  and,  as  the  interior  of  the 
uterus  is  the  source  of  infection  in  most  cases,  the  more  rational 
treatment  is  to  attend  carefully  to  this,  and  thus  prevent  the  extension 
of  inflammation,  so  far  as  is  possible,  to  the  sound  appendages.  Before 
deciding  to  leave  them  they  should  be  carefully  examined.  Should  pus 
be  found  to  exude  from  the  end  of  the  tube,  it  should  be  removed. 
Such  a  high  authority  as  Dr.  Howard  Kelly  (loc.  cit.,  vol.  ii.  p.  186) 
recommends  that  under  certain  circumstances  the  contents  of  the 
tube  should  be  squeezed  out  and  its  interior  washed  out  with 
saline  solution,  and  then  sterilised  with  i  in  5000  corrosive  sublimate 
solution.  It  is  difficult  to  believe  that  the  tube  can  be  effectually 
sterilised   in   this    way,    and   its    preservation    would    seem    to    invite 


REMOVAL  OF  THE   UTERINE  APPENDAGES.  549 

reinfection  of  the  peritouieal  cavity.  Until  more  evidence  is  forth- 
coming with  regard  to  this  procedure  it  appears  unsafe  to  recommend 
it  for  general  adoption.  On  the  subject  of  adhesions,  Dr.  Kelly  has 
laid  it  down  as  a  rule  that  these  do  not  in  themselves  constitute  a 
reason  for  the  removal  of  organs.  The  mere  presence  of  adhesions 
does  not  imply  that  the  organs  are  beyond  the  power  of  recovery, 
and,  in  fact,  there  is  plenty  of  clinical  evidence  to  the  contrary.  It 
has  already  been  mentioned  that  in  some  cases  the  persistence  of 
symptoms  is  due  rather  to  adhesions  binding  down  the  pelvic  organs 
in  abnormal  positions  than  to  the  presence  of  any  source  of  inflamma- 
tion. Under  these  circumstances,  operative  proceedings  may  be  limited 
to  the  separation  of  adhesions  and  the  fixation  of  organs  in  better 
position.  Dr.  Kelly  has  laid  stress  on  the  importance  of  not  only 
freeing  the  organs  from  surrounding  parts,  but  also  of  liberating  any 
kinks  in  the  tube,  a  condition  that  may  render  the  patient  liable  to 
tubal  pregnancy. 

Whilst  treatment  limited  to  the  freeing  of  organs  may  be  followed  in 
those  cases  in  which  the  inflammation  has  subsided,  it  should  not  be 
adopted  when  they  are  still  inflamed.  The  separation  of  adhesions 
without  removal  of  the  cause  is  certain  to  be  followed  by  the  formation 
of  fresh  ones,  besides  breaking  down  the  barrier  that  limits  the  spread 
of  infection. 

The  question  may  arise  as  to  whether  the  Fallopian  tube  should  be 
preserved  when  removal  of  the  corresponding  ovary  is  found  necessary. 

In  inflammatory  conditions  of  the  appendages,  it  is  uncommon  to 
find  a  case  in  Avhich  the  ovary  requires  removal  and  the  tube  is  found  in 
a  healthy  state.  Moreover,  the  tube  is  useless  without  the  ovary,  and, 
as  the  late  Mr.  Greig  Smith  has  pointed  out,  the  removal  of  the  latter 
will  probably  cause  kinking  of  the  tube.  Consequently,  if  the  ovary  is 
removed,  it  is  usuall}'  safer  to  remove  the  ,  tube  also  (loc.  supra  cit., 
p.  909).  It  might  be  left  if  operative  measures  have  resulted  in  the 
preservation  of  the  opposite  ovary,  but  removal  of  the  corresponding 
tube.  In  Dr.  Kelly's  case,  quoted  above,  pregnancy  followed  such  an 
operation,  leaving  one  ovary  and  the  opposite  tube. 

Those  conditions  have  been  pointed  out  in  •which  the  practice  of 
conservative  surgery  may  be  safely  advised.  But  there  are  certain 
operations  more  open  to  debate,  such  as  the  washing  out  of  tubes 
containing  pus,  the  amputation  or  resection  of  diseased  tubes,  and  the 
opening  of  closed  tubes.  In  the  hands  of  the  chief  advocates  of 
conservatism  these  procedures  have  met  with  results  that  may  be 
regarded  as  encouraging,  but,  with  our  present  information,  the}'  are 
not  operations  that  can  be  recommended  for  general  adoption. 


CHAPTER   XVII. 
OPERATIONS   ON    THE    UTERUS. 

REMOVAL  OP  MYOMATOUS  UTERUS  BY  ABDOMINAL 
SECTION.— CANCER  OF  THE  UTERUS. — REMOVAL  OF 
A  CANCEROUS  UTERUS  BY  ABDOMINAL  SECTION,— 
REMOVAL  OF  A  CANCEROUS  UTERUS  PER  VAGINAM. 
—  CiESARIAN  SECTION.  —  PORRO'S  OPERATION.  — 
ECTOPIC    GESTATION. 

REMOVAL    OF    MYOMATOUS    UTERUS    BY  ABDOMINAL 

SECTION. 

Indications  for  Operation. — A  fibroid  tumour  of  the  uterus  does 
not  by  its  presence  merely  afford  a  sufficient  indication  for  operation. 
It  must  either  give  rise  to  symptoms  which  threaten  life,  or  be  a  source 
of  such  discomfort  from  its  size  or  position  as  to  prevent  a  patient 
enjoying  a  reasonably  comfortable  existence  or  earning  a  livelihood. 
The  following  is  a  list  of  indications  that  justify  removal  of  a 
myomatous  uterus  : — 

(i)  Haemorrhage. — Profuse  haemorrhage  at  the  menstrual  periods  is 
the  symptom  that  is  the  commonest,  and  that  most  often  necessitates 
a  patient  seeking  advice.  The  amount  lost,  and  its  effect  on  the 
patient's  health,  the  influence  of  drugs  and  general  treatment,  the  age 
of  the  patient,  are  all  factors  to  be  taken  into  consideration.  The 
favourable  influence  that  the  change  of  life  often  has  on  these  tumours 
should  be  borne  in  mind,  and  if  a  patient  is  nearing  the  menopause  it 
may  be  advisable  to  recommend  her  to  wait  a  year  or  two.  The  fact 
that  it  is  generally  postponed,  and  often  deferred  till  after  fifty  years  of 
age,  should  be  remembered,  and  if  the  haemorrhage  is  very  profuse, 
leading  to  profound  anaemia,  and  very  little  relief  is  afforded  by  milder 
measures  of  treatment,  the  advisability  of  a  radical  operation  should  be 
put  before  the  patient. 

(2)  Pressure  Symptoms. — These  are  most  marked  in  the  case  of 
medium-sized  tumours  impacted  in  the  pelvis.  The  most  common 
symptom  is  frequent  or  difficult  micturition.  There  may  also  be 
trouble  in  keeping  the  bowels  open,  owing  to  pressure  on  the  rectum. 


EEMOVAL  OF  MYOMATOUS  UTERUS. 


551 


Or,  the  ureters  may  be  pressed  on,  and  hydro-nephrosis  or  pyelo- 
nephritis result.  These  symptoms  are  most  marked  just  before  the 
onset  of  the  menstrual  flow,  when  the  tumour  is  swollen  as  a  con- 
seqvxence  of  the  natural  engorgement  of  the  organs. 

Pain  in  association  with  fibroids  is  due  not  only  to  pressure  on 
nerves  and  neighbouring  organs,  but  also  to  attacks  of  peritonitis  and 
inflammation  of  appendages.  Dr.  Kelly  draws  special  "  attention  to 
the  fact  that  those  myomata  which  are  constantly  associated  with  great 
pain  almost  invariably  belong  to  the  class  of  complicated  cases  in  which 
a  tubal  or  ovarian  inflammatory  disease  will  also  be  found"  {loc.  cit., 
vol.  ii.  p.  367J. 

(3)  Great  Size. — A  large  tumour  in  the  abdomen  may  not  necessarily- 
threaten  life,  but  may  be  a  source  of  grave  inconvenience  and  discom- 
fort.    It  interferes  with  the  return  of  blood  from  the  lower  limbs,  and 

Fig.  214. 


Relation  of  the  ureters  and  uterine  arteries  to  the  cei-^-ix.     (Baldy.) 
L,     Uterus.  C,  Cervix. 

Ur,  Ureter.  Y,  Vagina. 

A,     Uterine  Ai'terj-.  B,  Section  of  l)ladder. 

SO  causes  oedema ;  it  presses  on  the  stomach  and  impedes  digestion ;  it 
limits  the  movements  of  the  diaphragm,  and  so  interferes  with  respira- 
tion; and.  by  preventing  an  active  existence,  leads  to  a  condition  of 
general  ill-health.  As  Mr.  Herman  {loc.  supra  cit.,  p.  822)  points  out, 
''  these  consequences  of  great  bulk  not  onlj'-  call  for  operative  cure  ; 
unfortunately  they  do  more :  the}'  add  to  its  risk.   ...  In  the  present 


552  OPERATIONS  ON  THE  ABDOMEN. 

state  of  abdominal  surgery,  the  risk  to  life  in  the  removal  even  of  a 
big  fibroid  is  small,  and  the  possible  undesirable  after-consequences  are 
less  grave  than  the  constant  presence  of  a  great  tumour.  A  well- 
advised  patient  will,  therefore,  welcome  relief  by  operation."' 

(4)  Rapid.  Growth  of  the  Tumour. — If  at  intervals  of  a  few  months 
the  tumour  is  found  to  be  markedly  increasing  in  size,  the  question  of 
its  removal  will  have  to  be  considered.  Very  rapid  enlargement  is 
usually  due  to  secondary  changes  occurring  in  it,  such  as  oedema, 
cj^stic  formation,  or  hfemorrhage,  A  sarcomatous  change  will  also  be 
responsible  for  a  rapid  growth,  but  is  of  rare  occurrence. 

(5)  Complications — due  to  associated  inflammatory  disease  of  the 
appendages  and  peritonasum,  tumours  of  the  ovary,  cancer  of  the 
uterus — will  call  for  operative  interference. 

There  are  three  methods  employed  in  the  removal  of  a  myomatous 
uterus,  in  two  of  which  the  hysterectomy  is  partial,  in  the  third  total. 
They  are  respectively : 

(i.)  Supra-vaginal  hysterectomy;  extra-peritonseal  treatment  of  stump. 

(ii.)  Supra-vaginal  In-sterectomy  ;  intra-peritonaeal  treatment  of 
stump. 

(iii.)  Total  hysterectomy-. 

(i.)  Supra- vaginal  Hysterectomy.  Extra-peritonaeal 
Treatment  of  Stump. 

Incision. — The  patient  having  been  prepared  as  for  ovariotomy,  an 
incision  is  made  in  the  median  line,  proportionate  to  the  size  of  the 
tumour  to  be  removed.  If  necessary  it  is  continued  upwards  to  the  left 
of  the  umbilicus.  The  incision  should  be  carried  well  down  towards 
the  pubes,  as  by  this  means  the  subsequent  steps  in  the  operation  are 
facilitated.  Especial  care  should  be  taken  in  dividing  the  peritonaeum, 
as  the  bladder  is  frequently  drawn  up,  and  thus  rendered  liable  to 
injury ;  moreover,  a  cut  made  accidentally  into  the  tumour  is  likely  to 
lead  to  very  troublesome  haemorrhage  difficult  to  arrest.  To  avoid  these 
dangers  the  peritonasum  should  be  pinched  up  towards  the  upper  part  of 
the  incision  and  carefully  examined  before  being  cut  through.  The 
opening  is  then  enlarged  iTpwards  and  downwards  on  two  fingers  used 
as  a  director,  the  height  to  which  the  bladder  ascends  being  in  this  way 
readily  detected. 

Delivery  of  Tumour. — A  hand  is  now  introduced  into  the  abdomen 
and  the  condition  present  noted.  Any  adhesions  found  must  be  dealt 
with.  These  present  much  more  difficulty  than  in  the  case  of  ovario- 
tomy, partly  on  account  of  the  size  of  the  tiimour,  and  the  fact  that  it 
cannot  be  diminished  b}^  tapping,  partly  on  account  of  the  bleeding 
that  follows  their  separation.  Mr.  Thornton  says  on  the  subject  of 
adhesions:  '•  If  the}^  are  present,  especiallj^  if  they  are  omental,  the}^ 
often  contain  enormous  vessels,  and  in  separating  them  great  care  is 
required  to  avoid  serious  loss  from  the  uterine  side  after  they  are  tied 
and  divided  on  the  proximal  side."  He  points  out  that  "adhesions  of 
large  surfaces  of  intestine  are  exceedingly  difficult  to  deal  with ;  there  is 
no  room  to  apply  ligatures  before  separating,  and  no  room,  or  not  firm 
enough  tissue,  to  ap2:)ly  pressure-forceps  after  separation  ;  thus  both 
surfaces  frequently  ooze  very  freely.  .  .  .  Sponge  pressure  is  the  only 
Avay  of  dealing  with  these  oozing  surfaces  "  (Allbutt  and  Playfair, 
Syst.  of  Gi/n.,  p.  615). 


EEMOVAL  OF  MYOMATOUS  UTERUS. 


553 


In  the  simplest  cases  the  tumour  is  seized  hold  of  and  brought  out  of 
the  wound,  care  being  taken  not  to  exercise  such  traction  as  will  result 
in  tearing  of  its  pedicle,  an  accident  that  may  cause  dangerous  bleeding. 
But  it  sometimes  happens  that  the  delivery  of  the  tumour  from  the 
abdomen  presents  great  difficulty,  and  it  may  be  found  necessary  to 
divide  the  broad  ligament  on  one  or  both  sides  before  this  can  be 
effected. 

Treatment  of  Ovaries  and  Bladder. — Before  the  ligaments  are  dealt 
AA'ith  the  operator  must  decide  whether  one  or  both  ovaries  shall  be 
preserved.  The  importance  of  saving  one  at  least  has  been  referred  to 
in  the  chapter  dealing  with  the    appendages.     Mr.  Thornton,  as  the 


Fio.  215. 


Fig.  216. 


The  lower  part  of  the  abdominal  wound  is 
shown  sutured  above  the  stump,  a,  a,  serre- 
noeud;  b,  h,  pin  passing  nearer  the  anterior; 
and  c,  c,  pin  passing  nearer  the  posterior 
boundaries  of  the  stump.     (Dorau.) 


Koeberle's  serre-uceud. 
(Galabin.) 


result  of  his  wide  experience,  says :  "I  always  leave  an  ovary  if  I  can, 
as  I  find  that,  if  this  be  done,  the  patients  recover  more  cjuickly  and 
completely,  and  sviffer  infinitely  less  at  the  change  of  life ;  especially  do 
they  escape  the  depression  which  is  apt  to  follow  the  complete  removal 
of  uterus  and  ovaries."  If  it  is  fovind  that  the  ovaries  are  healthy 
and  that  their  preservation  is  feasible,  the  surgeon  proceeds  to  divide 
the  broad  ligaments.  The  method  of  dealing  with  these  structures 
is    described  in    the    next   section   on   the    intra-peritonteal  operation. 


554 


OPERATIOXS  OX  THE  ABDOMEN. 


Whether  they  have  to  be  ligatured  and  divided  with  the  tumour 
in  the  abdomen,  or  brought  outside  it,  the  details  are  the  same.  Tlie 
next  point  requiring  careful  attention  is  the  bladder.  The  operator 
must  be  verj'  careful  that  this  is  not  included  in  the  rubber  or  wire 
ligature.  Some  surgeons  prefer  to  keep  the  bladder  full,  in  order  to 
define  its  limits,  but  this  is  not  necessary.  If  any  doubt  exists  as  to  the 
height  to  which  this  organ  extends  on  the  front  of  the  tumour,  a  sound 
should  be  passed.  If  it  ascends  over  the  part  to  which  the  constriction 
is  to  be  applied,  it  must  be  reflected  from  the  uterus.  To  carry  this 
out  an  incision  is  made  through  the  peritona3um,  from  side  to  side,  half 
an  inch  above  the  bladder,  and  this  organ  carefully  separated  by  means 
of  the  finger  from  the  uterus. 

Treatment  of  Pedicle. — The  constriction  of  the  pedicle  may  be 
effected  either  by  means  of  wire  or  rubber  ligature.  If  the  former 
method  is  to  be  made  use  of.  thick,  soft  iron  wire,  that  will  not  readily 
cut  through  the  tissues,  should  be  employed,  and  the  best  form  of  clamp 
is  Koeberle's  serre-noeud.  The  wire,  having  been  adjusted  round  the 
neck  of  the  tumour,  is  slowly  tightened  up  by  means  of  the  clamp. 
Two  transfixion  pins  are  then  passed  through  the  pedicle  immediately 


Fig.  217. 


Siq^ra-vagiual  hj-sterec-tomy.  lutra-peritouaeal  treatment  uf  stump, 
showing  mode  of  division  of  broad  ligaments  and  reflection  of 
anterior  flap  with  bladder.     Uterine  vessels  are  tied  and  divided. 

above  the  wire,  and  the  tumour  cut  away  about  an  inch  above  the  pins. 
Instead  of  A\ire  an  elastic  rubber  ligature  may  be  emploj^ed.  Professor 
Hegar  used  an  india-rubber  cord  five  millimetres  thick,  which  by  means 
of  a  special  needle  \\as  made  to  transfix  the  cervix.  The  two  halves  were 
then  tied  separately,  and  the  whole  cervix  encircled  by  another  ligature 
placed  below  the  two  preceding  ones.  The  double  ligature  does  not 
appear  to  be  necessary,  and  one  rubber  ligature  drawn  round  the  cervix 
is  sufficient ;  means  being  taken  to  prevent  it  slipping  by  grasj)ing  the 
knot  in  a  pair  of  forceps.  There  \\'ill  probably  be  some  shrinkage  of 
the  stump  as  the  tumour  is  cut  awa}',  necessitating  the  tightening  up 


REMOVAL  OF  MY03L\T0US  UTERUS.  555 

of  the  ^\'ire  by  a  few  turns  of  the  screw  of  the  clamp.  The  stump  is 
pared  carefully,  either  now  or  after  closure  of  the  abdominal  incision. 
Mr.  Thorburn,  to  whom  so  many  details  of  the  operation  in  its  present 
form  are  due,  pares  down  the  stump  as  much  as  possible,  especially 
cutting  away  the  inside  fibrous  and  muscular  tissue  into  a  somewhat 
cupped  shape.  It  has  been  recommended  that  the  peritonaeum  of  the 
pedicle  should  be  drawn  over  the  cut  sm-face  of  the  stump  and  sutured 
there.  This  is  unnecessary,  and,  as  Mr.  Thorburn  points  out,  merely 
serves  to  enclose  materials  which  are  much  better  escaping  into  the 
dressings.  The  peritonaeum  of  the  abdominal  wall  is  now  secured  to 
that  of  the  pedicle  below  the  wire  by  two  or  three  sutures,  and  the 
^•entral  incision  closed  in  the  usual  way.  The  stump  is  powdered  with 
iodoform  and  dressed  with  iodoform  gauze,  care  being  taken  to  insert 
several  layers  of  gauze  beneath  the  pins  and  the  clamp. 

After-treatment. — The  dressing  should,  if  possible,  be  left  untouched 
for  a  few  daj's,  one  or  two  turns  of  the  screw  being  made  in  the  case 
of  large  pedicles.  The  stump  is  often  ready  to  come  away  in  two  or 
three  weeks'  time.  If  it  does  not  then  show  signs  of  doing  so,  it  may  be 
clipped  down  to  the  wire  and  pins,  and  these  latter  removed  altogether. 
Mr.  Thornton  recommends  that  some  of  the  sutures  of  the  abdominal 
wall  should  be  left  longer  than  usual,  as  there  is  a  greater  tendency  to 
reopening  of  tlu-  wound  than  in  the  case  of  ovariotomy. 

ii.  Supra  -  vaginal  Hysterectomy.  Intra-abdominal 
Method. 

The  mode  of  operation  described  is,  in  its  essentials,  that  associated 
with  the  name  of  Dr.  Baer,*  of  Philadelphia.  The  principles  on  which 
he  based  his  operation  were  :  "  First,  control  of  haemorrhage  b}'  ligature 
of  the  blood-vessels  in  the  broad  ligaments ;  second,  non-constriction  of 
the  cervical  tissues,  so  that  there  shall  be  no  cause  of  suppuration  ;  and 
third,  non-disturbance  of  the  cervical  canal,  so  that  sepsis  from  the 
vagina  may  be  prevented."  Dr.  Kelly  (loc.  supra  cit.,  p.  365)  draws 
attention  to  the  fact  that  the  ver}-  important  step  of  systematically  secur- 
ing the  ovarian  and  uterine  arteries  in  their  course,  as  a  preliminary  to 
hysterectomy,  was  devised  by  Dr.  L.  A.  Stimson,  of  New  York. 

The  Operation. — The  initial  stages  of  the  operation  are  similar  to 
those  described  in  the  extra-abdominal  method.  It  will  be  considerably 
facilitated  in  some  cases  by  placitig  the  patient  in  the  Trendelenberg 
position.  The  incision  having  been  made  through  the  abdominal  wall, 
the  condition  of  the  parts  examined  and  adhesions  dealt  with,  the 
tumour  is  delivered  as  previously  described.  As  in  the  preceding 
method,  it  ma}'  be  found  necessary  to  deal  with  the  broad  ligaments 
before  delivering  the  tumour,  and  to  divide  part  of  them  on  one  or  both 
sides  with  the  uterus  still  in  the  abdomen.  The  steps  of  this  part  of 
the  operation  are  similar  to  those  taken  when  the  tumour  can  be 
brought  through  the  ventral  incision. 

Division  of  Broad  Ligaments. — The  uterus  having  been  drawn  out  of 
the  abdomen,  the  operator  carefully  examines  the  broad  ligaments  and 
appendages  on  each  side,  and  decides  whether  he  will  leave  one  or  both 
ovaries,  or  whether  he  will  remove  them  both.      When  possible,  one  at 


*  This  method  of  operation  was  published  in  the   Transeutions  of  the  Amerivan 
(j ijuacological  ^ocictij,  vol.  xvii.  (1892),  p.  234,  and  vol.  xviii.  p.  62. 


556  OPE  RATIONS  ON  THE  ABDOMEN. 

least  should  be  saved,  exception  being  made  in  those  cases  in  which  they 
are  found  diseased,  oi*  when  it  is  found  impossible  to  leave  them,  or  the 
patient  has  reached  the  menopause.  The  surgeon,  after  carefully 
examining  both  sides,  chooses  that  which  can  most  easil}^  be  dealt  with, 
and,  seizing  the  upper  part  of  the  broad  ligament,  passes  through  it,  at 
a  point  free  from  vessels,  a  blunt  pedicle-needle  threaded  with  No.  3  silk. 
The  exact  point  of  perforation  ^^■ill  depend  upon  whether  the  ovar}^  is 
to  be  removed  or  not ;  in  the  former  case  the  ligature  will  be  carried 
round  the  free  edge  of  the  broad  ligament ;  in  the  latter  it  will  include 
the  Fallopian  tube. 

This  ligature,  which  secures  tlie  ovarian  artery,  is  then  firmlv  tied, 
and  that  portion  of  the  broad  ligament  next  the  tumour  being  secured 
by  means  of  forceps,  the  part  intervening  between  the  ligature  and  the 
forceps  is  divided  (Fig.  217).  A  second  ligature  is  passed  through 
the  broad  ligament  of  the  same  side,  lower  down,  including  the  round 
ligament,  and  firmly  tied ;  the  proximal  portion  of  the  broad  ligament 
is  clamped,  and  the  part  between  forceps  and  ligature  divided.  In  most 
cases  these  two  ligatures  will  be  found  sufficient,  but  more  can  be 
applied  in  the  same  way  if  required.  The  use  of  forceps  for  clamping 
the  proximal  part  of  the  ligament,  as  described  above,  rather  than 
ligatures,  will  be  found  to  effect  a  saving  of  time.  The  opposite  side 
is  then  dealt  with  in  the  same  way. 

Formation  of  Anterior  Flap. — The  next  step  in  the  operation  is  the 
reflection  of  a  flap  of  peritona3um  and  the  bladder  from  the  front  of  the 
uterus.  An  incision  is  made  through  the  peritoneum  covering  the  front 
of  the  uterus,  from  side  to  side,  about  an  inch  above  the  line  of  attach- 
ment of  the  bladder,  the  position  of  which  should  be  carefully  ascer- 
tained. It  should  be  carried  across  to  join  at  each  extremity  the  lower 
end  of  the  cuts  in  the  broad  ligaments.  The  bladder  is  then  separated 
from  the  uterus  by  means  of  the  finger,  any  firmer  bands  (and  these  are 
met  with  especially  in  the  median  line)  being  divided  with  scissors. 
Care  should  be  taken  in  this  separation,  as  the  bladder  is  sometimes 
much  thinned  by  stretching,  and  it  does  not  recjuire  much  force  to  push 
the  finger  through  into  its  interior.  Should  this  accident  happen,  the 
opening  must  at  once  be  closed  with  sutures.  A  small  peritonseal  flap 
may  be  raised  on  the  posterior  siirface  of  the  uterus,  but  this  is  not 
necessary-,  and  ma}^  quite  well  be  dispensed  with.  By  the  reflection  of 
the  anterior  flap  some  loose  cellular  tissue  on  each  side  of  the  neck  of 
the  myomatous  uterus  is  exposed,  and  in  this  there  may  be  felt 
pulsating,  and  sometimes  seen,  the  iiterine  artery. 

Ligature  of  Uterine  Artery. — The  position  of  the  artery  is  now  care- 
fully defined  on  one  side,  and  a  silk  ligature  threaded  on  a  pedicle- 
needle  is  passed  through  the  cellular  tissue  between  the  artery  and  the 
uterus.  A  pair  of  Spencer  Wells's  forceps  are  now  applied  so  as  to 
include  the  artery  a  little  above  the  ligature,  and  the  latter  is  firmly 
tied.  The  tissues,  including  the  uterine  artery,  are  then  divided 
between  the  ligature  below  and  the  forceps  above,  and  if  the  ligature 
has  been  properly  applied  there  will  be  no  bleeding.  If  the  artery  has 
not  been  secured  it  will  spiu't  on  division,  and  should  be  promptly  seized 
with  forceps  and  tied.  The  same  procedure  is  adopted  on  the  opposite 
side. 

Removal  of  Uterus, — -A  point  has  now  been  reached  at  Avhicli  the 


PtE3I0VAL  OF  MYOMATOUS  UTERUS.  557 

blood-supply  has  been  secured,  and  nothing  is  left  keeping-  the  enlai"ged 
uterus  in  position  but  the  narrow  neck  below.  The  only  remaining 
step  is  to  divide  this  latter.  The  intestines  being  kept  out  of  the  way, 
the  left  hand  is  passed  down  behind  the  neck  to  prevent  the  possibility 
of  injury  to  l^owel,  and  the  pedicle  is  divided  with  knife  or  scissors  just 
above  the  point  at  which  the  uterine  arteries  are  secured. 

The  division  of  the  pedicle  is  effected  in  various  ways.  The  simplest 
method  is  to  make  an  incision  straight  through,  so  as  to  leave  a  flat  raw  sur- 
face, which  is  subsequently  covered  in  by  the  peritonosal  flaps.  Dr.  Baer, 
in  his  original  description  (loc.  sup.  cit.),  considered  that  in  most  cases  it 
was  sufficient  to  allow  the  flaps  to  fall  together  over  the  stump,  and  that 
there  was  no  need  to  suture  them.  To  render  the  stump  completely 
extra-peritona?al  it  is  better,  however,  to  accurately  coapt  the  cut  edges 
of  the  peritoufeum.  This  is  effected  by  means  of  a  continuous  silk 
suture.  The  divided  edges  of  the  broad  ligament  on  one  side  are  first 
sewn  together.  The  anterior  flap  of  peritona3um  is  then  drawn  over  the 
stump,  and  its  free  border  sutured  to  the  cut  edge  of  peritonaeum  at  the 
back  of  the  stump,  the  operation  being  completed  by  sewing  together 
the  two  edges  of  the  remaining  broad  ligament.  In  defining  the 
principles  on  which  this  operation  was  based.  Dr.  Baer  laid  stress  on  the 
importance  of  not  disturbing  the  plug  of  mitcus  in  the  cervical  canal,  as 
he  regarded  this  as  a  bar  to  the  spread  of  infection.  Though  in  healthy 
women  the  interior  of  the  uterus  appears  to  be  free  from  organisms,  in 
some  cases  of  fibroids  there  is  a  purulent  discharge  from  the  organ,  and 
one  objection  made  to  the  simjole  division  of  the  cervix  is  that  infection 
of  the  wound  may  take  place  from  the  cervical  canal.  To  prevent  this 
happening,  the  closure  of  the  canal  is  recommended  by  some  operators. 
This  may  be  effected  by  making  the  incision  through  the  cervix, 
V-shaped,  and  approximating  closely  the  two  flaps  by  sutures.  Dr.  Kelly 
prefers  to  so  hollow  out  the  stump  as  to  leave  it  cup-shaped,  the  canal 
lieing  closed  by  sutures,  which  are  passed  from  before  backwards,  and 
which  convert  the  cup  into  a  transverse  linear  wound.  As  a  further 
precaution  against  infection  the  canal  may  be  excised  with  knife  and 
scissors  or  cauterised.  Sutures  passing  through  the  cervix  are  not, 
however,  free  from  objection,  as  they  may,  themselves,  become  septic, 
and  convey  infection  to  the  wound  surfaces.  Though  the  closure  of 
the  canal  has  met  with  admirable  results  in  the  hands  of  some  surgeons, 
it  is  not  regarded  with  favour  by  all.  Mr.  Doran,  in  opening  a  discus- 
sion on  the  treatment  of  fibroids  (Brit.  Med.  Journ.,  Sept.  15,  1900) 
did  not  advocate  the  closing  of  the  stump  b}-  sutures,  as  he  considered 
this  procedure  was  liable  to  be  followed  by  sloughing. 

Comparison  of  the  Intra-  and  Extra-peritonaeal  Methods. — The 
weak  points  of  the  extra-peritona?al  method  are  these  : — 

(1)  The  prolonged  convalescence,  lasting  for  six  or  eight  weeks,  while 
the  slough  is  separating.  After  the  intra-abdominal  method  the  Mound 
quickl}^  heals,  and  the  patient  is  able  to  get  up  in  three  or  four  weeks' 
time.  This  is  generally  held,  and  I  think  rightly,  to  be  a  great  advan- 
tage ;  but  Mr.  Herman  does  not  consider  it  to  be  so  great  as  might  be 
thought,  as  the  nervous  shock  caused  by  the  operation,  and  consequently 
the  time  required  to  regain  the  former  energy,  is  the  same  in  both 
cases. 

(2)  The  granulating  area  in  the  abdominal  wall  leaves  a  cicatrix  which 


558  OPERATIONS  OX  THE  ABDOMEX. 

is  liable  to  yield  and  give  rise  to  a  v^entral  hernia.  Though  a  hernia 
may  arise  after  careful  and  close  suture  of  an  abdominal  wound  in  its 
whole  length,  it  is  much  more  common  in  those  cases  in  which  part  of 
the  incision  is  allowed  to  close  by  granulations,  as  when  drainage  is 
employed  or  after  the  separation  of  the  stump  in  extra-peritonagal 
hysterectomy. 

Mr.  E.  S.  Bishop  (Uterine  Fihro-myomata,  1901,  p.  304),  writing  on 
the  subject  of  hernia  after  hysterectomy  for  fibroids,  says :  "  Since 
drainage  through  the  abdominal  wound  has  been  entirely  given  up,  and 
special  care  has  been  directed  to  the  suture  of  the  fascia,  I  have  only  seen 
one  hernia,  and  that  followed  suppuration  in  the  wound  due  to  an  im- 
perfectly asepticised  suture."  As  showing  the  frequency  of  hernia  after 
the  extra-peritonaeal  method,  Mr.  Cullingworth's  experience  may  be 
quoted.  Of  ten  cases  so  treated  by  him,  two  died,  and  five  subsequentl}' 
suffered  from  hernia  in  various  degrees  (quoted  by  Mr.  Bishop,  he.  sup-a 
cit.,  p.  221). 

(3)  Another  weak  point  in  the  operation  is  the  risk  of  septic  absorp- 
tion attending  the  necessary  sloughing  of  the  stump. 

(4)  In  comparing  the  mortality  of  the  intra-  and  extra-peritonaeal 
operations,  it  should  be  remembered  that  the  former  method  has  a  wider 
range  of  utility  than  that  in  wliich  the  stump  is  fixed  in  the  abdominal 
wall.  There  are  many  cases  in  which  it  would  be  found  very  difficult 
or  impossible  to  draw"  the  pedicle  up  into  the  ventral  incision,  and 
which  can  be  readily  dealt  with  by  the  intra-abdominal  method. 

Weill  (An7i.  de  Gi/nec,  1899,  vol.  Hi.  p.  28)  in  392  cases  of  extra- 
peritongeal  treatment  of  the  stump,  collected  by  him  from  various  sources, 
found  the  mortality  to  be  i8'6  per  cent.  For  purposes  of  comparison 
it  is  better,  perhaps,  to  take  the  figures  of  one  expert  operator.  Mr. 
Thornton  states  that  the  mortality  of  his  cases  was  just  under  8  per  cent.; 
but  these  included  all  his  early  work.  Practice  with  the  serre-ncEud 
has  reduced  his  mortality  by  fully  one-half,  and  he  considers  that 
•'  cases  suitable  for  the  serre-noeiid,  in  which  there  is  no  unusually  severe 
complication,  may  fairly  be  said  to  have  a  mortality  of  only  3  or  4  per 
cent."'  (loc.  supra  cit.,  p.  621). 

Xoble  has  collected  345  cases  of  supra-vaginal  amputation  with  intra- 
peritonseal  treatment  of  the  stump,  and  found  the  mortality  to  be  4*9  per 
cent.  In  the  practice  of  individual  men  the  death-rate  is  lower  than 
this.  Dr.  Gow  (Med.  Press  and  Give.,  1900,  vol.  i.  p.  129)  gives  a  list  of 
fortj'-seven  operations  performed  by  him  with  only  one  death  :  and  Dr. 
Howard  Kelly  states  that  "  in  one  hundred  consecutive  abdominal 
hysterectomies,  including  all  kinds  of  complications,  I  have  lost  two 
cases." 

In  comparing  statistics  collected  from  all  sources,  there  is  seen  to 
])e  a  great  difference  in  the  mortality;  18 '6  per  cent,  for  the  extra- 
peritonaeal  as  compared  with  4*9  per  cent,  for  the  intra-peritoneal  method. 
Such  a  comparison,  however,  is  not  of  great  value,  as  the  former  figures 
include  many  operations  performed  before  the  modern  improvements  in 
technique,  whereas  the  latter  percentage  is  based  on  comparatively 
recent  work.  There  is  probably  not  ver}^  much  difference  in  the  death- 
rate  of  the  two  methods  in  the  hands  of  expert  operators,  and  what 
difference  there  is  may  fairly  be  said,  in  the  face  of  recent  results,  to 
1)6  in   favour  of  the  intra-peritonseal  operation.      This  being  so,   the 


REMOVAL  OF  MYOMATOUS   UTERUS.  559 

treatment  by  the  clamp  loses  its  chief  claim  on  our  consideration,  for 
in  no  other  respect,  either  in  rapidity,  in  its  applicability  to  the  varying 
conditions  found,  or  in  its  freedom  from  subsequent  complications,  does 
it  compare  with  the  intra-abdominal  method. 

iii.  Total  Hysterectomy. 

This  may  be  called  for  in  certain  cases  ;  when  the  uterus,  for  instance, 
is  the  seat  of  malignant  growth,  or  when  the  position  of  a  fibroid  tumour 
does  not  permit  of  division  through  tlie  cervix. 

The  operation  is  similar  to  that  of  partial  hysterectomy,  as  far  as  the 
ligature  of  the  uterine  arteries. 

Opening  of  Vagina. — These  arteries  having  been  secured,  the  tumour 
is  held  forward,  and  an  opening  is  made  through  the  bottom  of 
Douglas's  pouch  into  the  posterior  fornix,  upon  the  end  of  a  pair  of 
forceps  previously  introduced  through  the  vagina.  A  finger  is  then 
passed  through  the  opening  thus  made,  and  carried  forward  across  the 
cervix  to  act  as  a  guide  to  the  opening  of  the  anterior  fornix.  The 
position  of  the  already  reflected  bladder  is  then  carefully  noted,  and  the 
vagina  again  opened  with  scissors  upon  the  finger  in  the  anterior  fornix. 
The  anterior  and  posterior  incisions  are  next  freely  lengthened,  leaving 
the  lateral  attachments  only  of  the  vagina  to  the  uterus.  These  should 
be  secured  with  clamp  forceps,  and  the  uterus  removed  by  incisions 
carried  between  the  forceps  and  the  cervix.  The  forceps  are  then  re- 
moved, one  at  a  time,  and  a  careful  examination  made  for  any  bleeding 
points,  which  should  be  secured  and  tied  separately. 

Closure  of  Peritonaeum. — The  next  step  is  to  unite  the  cut  edges  of 
peritonajum,  and  thus  shut  off  the  opening  into  the  vagina  from  the 
peritonfeal  cavity.  An  iodoform  gauze  plug  is  introduced  into  the  vagina 
from  above,  and  drawn  down  until  its  upper  end  is  level  with  the  cut 
edges  of  the  vagina.  The  operator  then  proceeds  to  approximate  the 
edges  of  the  peritonaBum  with  a  continuous  suture.  Having  sewn 
together  the  two  layers  of  the  lower  part  of  the  broad  ligament  on  one 
side,  the  anterior  peritonseal  flap  is  brought  o^•e^  the  vaginal  opening 
and  secured  to  the  posterior  cut  edge  of  peritonaeum,  the  operation  being 
completed  by  the  closure  of  the  In'oad  ligament  on  the  remaining  side. 

Dr.  Howard  Kelly's  Method  of  performing  Partial 
Hysterectomiy   (Hy stero-myomectomy ) . 

Dr.  Kelly  adopts  a  different  procedure  from  that  described  above. 
Instead  of  tying  and  dividing  the  broad  ligaments  on  both  sides  before 
severing  the  pedicle,  he  works  across  the  pelvis  from  one  side  to  the 
other,  dividing  first  one  broad  ligament,  then  the  pedicle,  and  finally 
dealing  with  the  other  broad  ligament. 

The  stages  of  the  operation  as  described  by  him  (loc.  sujjra  cit.,  p.  368) 
are  shortly  as  follows : — 

(a)  Preliminary  Preparation  of  the  Field  of  Operation,  including 
the  Skin  and  Vagina. 

(h)   Opening  the  Abdomen. 

(c)  Delivering  the  Tumour,  if  possible. 

(d)  Ligation  of  the  Ovarian  Vessels  and  Round  Ligament  of 
one  side,  usually  the  left. 

In  a  woman  \inder  forty  years  of  age  he  considers  it  better  to  leave 
both  ovaries  in  the  pelvis,  with  or  without  the  uterine  tubes.  The 
broad   lig-ament  is  divided  between  two  sets  of  ligatures,  or  between 


56o 


OPERATIONS  OX  THE  ABDOMEN. 


forceps  on  the  proximal  and  ligatures  on  the  distal  side,  as  previously 
described. 

(e)  Detachment  of  the  Vesico-uterine  Fold  of  Peritonseum. — The 
uterus  being  drawn  back,  '"  the  anterior  loose  peritona?al  fold  along  the 
curved  line  of  the  utero-vesical  reflection  is  cut  through  from  round 
ligament  to  round  ligament.  As  the  bladder  is  raised,  the  loose  cellular 
tissue  beneath  it  is  exposed,  and  it  may  be  still  further  freed  by  a  rapid 
dissection  with  knife  or  scissors."  The  separation  of  the  bladder  is 
completed  by  pushing  it  well  down  with  a  sponge  firmly  compressed  in 
sponge-forceps,  until  the  cervix  is  bared  almost  or  quite  down  to  the 
vaginal  junction. 

Fig.  2i8. 


The  operation  of  hj-stero-inyomectomy.    (Kelly.) 

By  a  coutiuuous  incision  from  left  to  right,  ligating  or  clamping — at  the  points 
indicated  by  the  arrows — first,  the  left  ovarian  vessels  (Ov.  ves.) ;  next,  the 
round  ligament,  and  then  the  left  uterine  artery  (Ut.  Art).  Finally,  the  cervix 
is  cut  across,  and  the  uterus  pulled  away  until  the  right  uterine  vessels  are 
exposed. 

(/)  Ligation  of  the  Uterine  Vessels  of  the  same  side. — These 
vessels  are  now  securely  tied  close  to  the  cervix  by  a  silk  ligature  on  a 
curved  needle  passed  close  to  the  cervical  tissue  but  not  entering  it. 

(g)  Amputation  of  Uterus  in  Cervical  Portion. — The  uterus  is 
now  drawn  to  the  other  side,  and  the  uterine  vessels  are  divided  from 
6-IO  mm.  above  the  ligature,  an  assistant  being  ready  with  artery- 
forceps  to  grasp  any  bleeding  vessel  left  by  chance  out  of  the  ligature. 
The  utei'us  is  now  completely  di\^ded  in  its  cervical  portion,  at  a  point 
just  above  the  vaginal  junction,  and  in  such  a  w^ay  as  to  leave  a  cup- 
shaped  pedicle.  It  is  a  good  plan,  when  the  cervix  is  nearly  divided,  to 
cut  upward  for  one  or  two  centimetres  so  as  to  leave  behind  a  thin  shell 


CANCER  OF  THE  UTERUS.  561 

of  cervical  tissue,  and  expose  the  opposite  uterine  vessels  at  a  higher 
level,  when  it  is  much  easier  to  tie  them  without  risk  of  including  the 
ureter." 

(h  )  Clamping  the  Uterine  Vessels  of  opposite  side,  the  Round 
Ligament,  and  the  Ovarian  Vessels,  followed  by  Removal  of  the 
TumoTir. — As  the  uterus  is  drawn  up  and  rolled  over  on  to  its  side,  the 
uterine  vessels  come  into  view  ;  these  are  seized  in  clamp  forceps  and 
divided.  The  uterus  is  rolled  over  still  more  till  the  round  ligament  is 
seen,  which  is  clamped  and  divided,  followed  by  similar  treatment  of  the 
ovarian  vessels.     The  whole  mass  is  thus  freed  and  taken  away. 

(i)  Application  of  Ligatures  in  place  of  Forceps, — The  parts  now 
held  in  forceps  (the  ovarian  vessels,  the  round  ligament,  and  the  uterine 
vessels)  are  successively  tied  with  firm  silk  ligatures  and  the  forceps 
removed. 

(j)  Suturing  the  Cervical  Stump. — The  stump  is  carefully  examined 
for  any  bleeding  points,  which  should  be  tied.  It  is  now  closed  over 
the  cervical  canal  by  passing  from  three  to  five  or  more  catgut  sutures 
in  an  antero-posterior  direction,  and  tying  each  one  as  it  is  passed.  By 
suturing  in  this  way  the  cup-shaped  pedicle  is  changed  into  a  transverse 
linear  wound.  Should  there  be  a  discharge  of  pus  from  the  uterus  or  a 
muco-purulent  plug  in  the  canal,  this  latter  should  be  wiped  out  with 
gauze  as  soon  as  cut  across,  and  afterwards  dissected  out  with  a  sharp 
knife  and  forceps. 

(A)  Covering  the  Wound-Area  with  Peritonseum. — The  large  flap 
of  peritonaeum  which  lies  in  front  of  the  pedicle  is  drawn  over  the 
stump  and  sutured  to  the  posterior  peritonaeum  by  a  continuous  suture. 


CANCER  OF  THE  UTERUS. 

Cancer  of  the  Body. — In  cases  suitable  for  radical  treatment  the 
uterus  may  be  removed,  either  through  the  vagina  or  by  an  abdominal 
incision,  the  choice  of  route  being  determined  by  the  size  of  the  body. 
The  indications  for  operation  are  practically  the  same  as  those  given  in 
the  next  section  on  cancer  of  the  cervix.  Should  the  abdominal  route 
be  chosen,  the  operation  is  in  all  essentials  similar  to  that  described  for 
fibroids,  the  whole  of  the  uterus  being  of  necessit}'  removed.  Hyste- 
rectomy by  the  vaginal  route  is  similar  to  that  described  foi"  carcinoma 
of  the  cervix. 

Vaginal  Hysterectomy  for  Carcinoma   of  the  Cervix. 

To  cleteriiiine  n-lietlier  Cose  is  saltaJde  for  Ileinoral  of  tJte  Uterus. — It  is 
not  easy  in  a  case  of  cancer  of  the  cervix  to  say  whether  the  whole 
disease  can  be  eradicated,  as  growth  may  have  extended  beyond  the 
limits  of  the  uterus,  and  yet  be  inappreciable  on  the  most  careful 
examination. 

To  determine  whether  a  case  is  operable,  the  different  routes  by 
which  the  growth  may  advance  must  be  carefully  borne  in  mind,  and 
a  systematic  examination  made  of  each.     They  are  as  follows :  - 

(1)  The  growth  may  involve  the  fornices  or  extend  down  on  to  the 
vaginal  walls. 

(2)  It  may  extend  forwards  and  involve  the  bladder. 

(3)  It  may  extend  outwards  in  the  broad  ligaments. 

VOL.    II.  T,6 


562  OPERATIONS  OX  THE  ABDOMEN. 

(4)  Or  extend  backwards  in  the  ntero-sacral  folds  and  involve  tlie 
rectum. 

In  examining  a  case  the  first  thing  to  be  noted  is  the  mobility  of  the 
uterus.  This  may  be  tested  most  efficiently  by  fixing  a  pair  of  ten- 
aculum forceps  into  the  cervix,  and  observing  whether  the  organ  can 
be  drawn  down  readily  towards  the  vulva.  If  there  is  complete  or 
considerable  fixation  and  extension  of  growth  in  any  of  the  above- 
mentioned  directions  the  case  is  inoperable,  and  should  be  left  alone. 
The  cervix  should  be  examined,  not  only  digitally,  but  through  a 
speculum,  and  the  extent  to  which  the  fornices  or  the  walls  of  the 
vagina  are  involved  carefully  noted.  To  determine  whether  extension 
laterally  into  the  broad  ligaments  or  backwards  in  the  utero-sacral  folds 
has  taken  place,  the  vaginal  examination  must  be  supplemented  l)y  a 
rectal  one,  and  a  search  made  for  an}-  masses  or  thickening  in  these 
situations. 

If  the  uterus  is  freely  movable,  and  can  be  pulled  down  to  the 
vulva,  and  there  is  nothing  to  be  felt  in  the  broad  ligaments  or  utero- 
sacral  folds,  the  case  is  a  favourable  one  for  operation,  and  there  are 
good  grounds  for  hope  of  permanent  relief. 

But  between  the  eminently  favourable  cases  and  those  that  are  to  be 
regarded  as  inoperable,  certain  cases  are  to  be  met  with,  not  infre- 
quentl}',  in  which  there  exists  an  element  of  doubt  as  to  whether  the 
gro-w-th  can  be  entireh'  removed.  On  this  point,  Dr.  Howard  Kelly's 
remarks  are  worth  Cjuoting:  "In  concluding  wliether  or  not  to  operate, 
the  patient  should  in  all  cases  have  the  benefit  of  any  reasonable  doubt, 
and  the  operator  must  not  be  too  exacting  in  restricting  his  indications. 
I  have  operated  several  times  where  the  disease  was  found  so  advanced 
that  there  could  be  no  reasonable  question  but  that  some  portion 
of  it  was  left  behind,  and  this  was  confirmed  by  a  microscopic 
examination  of  the  specimen,  which  showed  cancer  cells  right  up  to  tlie 
cut  edge  of  the  broad  ligament,  and  yet  one  of  these  patients  enjoyed 
perfect  health  for  five  years,  when  the  disease  reappeared  in  the  glands 
of  the  neck ;  another  had  a  local  return  after  three  years  of  good 
health,  and  two  others  are  living,  apparently  in  perfect  health,  three 
and  four  years  after  the  operation"  (loc.  supra  cit.,  p.  319). 

Is  an  operation  justifiable  in  cases  in  which  no  hoj^e  can  be  reason- 
ably entertained  of  a  permanent  cure  ?  In  considering  this  question, 
the  influence  that  repeated  losses  of  blood  and  contiiuious  sej^tic  absor])- 
tion  from  the  breaking-down  cancerous  mass  have  on  the  health  of  the 
patient  should  be  borne  in  mind.  If  under  the  circumstances  there  is 
reason  to  think  that  the  uterus  can  be  removed  without  unusual  risk, 
the  surgeon  is  justified  in  operating  after  laying  the  facts  of  the  case 
fairl}'  before  the  patient.  For  recurrence  of  the  disease,  so  long  as  it 
does  not  take  place  in  the  vaginal  roof,  will  be  attended  with  less  pain, 
an  absence  of  hgemorrhage  and  a  relief  from  the  distress  dependent  on 
a  foetid  discharge. 

Xo  radical  operation  should  be  undertaken  if  extension  of  growth 
lias  led  to  involvement  of  bladdei',  ureters,  or  rectum.  Wide  extension 
into  the  broad  ligaments  \\'ill  give  rise  to  grave  danger  of  injury  to  tlie 
ureters.  Moreover,  difficulty  will  be  experienced  in  tlie  application  of 
ligatures  or  forceps,  ^^■llicll  are,  further,  likely  to  slip  off'  from  the  friable 
cancerous  growth. 


CAXCER  OF  THE  UTERUS.  563 

Palliation  may  be  afforded  in  some  inoperable  cases  by  a  free  scraping 
away  of  the  gTowtli  in  the  cervix,  followed  by  the  application  of 
Paquelin's  cantery.  Great  hopes  of  relief  should  not  be  held  out  to 
the  patient  as  likely  to  follow  this  jirocedure.  nor  should  the  operation 
be  urged  on  her.  The  growth,  with  its  attendant  htemon'hage  and 
discharge,  may  recur  very  soon,  and  on  one  or  two  occasions  extension 
of  the  growth  has  appeared  to  me  to  be  accelerated 

Operation. — There  are  many  modifications  in  the  various  stages  of 
this  operation  adopted  by  different  surgeons,  the  chief  of  which  is  the 
treatment  of  the  broad  ligaments,  some  preferring  to  tie  these  with 
silk  or  catgut,  others  to  clamp  them. 

Preliminary  Treatment. — For  some  days  beforehand  the  vagina 
should  be  freely  douched  with  some  antiseptic  lotion,  such  as  1-500 
formalin. 

For  the  operation  the  patient  is  placed  in  the  lithotomy  position,  and 
the  legs  secured  by  means  of  a  Clover's  crutch.  The  perimeum  is 
retracted  with  a  Sim's  or  .Simon's  speculum.  Lateral  retractors  may 
be  found  useful  at  certain  staues  of  the  operation.  The  cer^•ix  is  drawn 
down  to  the  vulva  by  vulsella,  one  pair  of"  forceps  being  applied,  as  a 
rule,  to  the  anterior  lip,  one  to  the  posterior.  The  point  of  attachment 
will,  however,  depend  to  some  extent  on  the  condition  of  the  cervix. 
In  the  case  of  large  cauliflower  excrescences  it  will  often  be  foiind 
necessrfly.  as  a  preliminary  to  freeing  the  uterus,  to  remove  the  groAxi"!! 
freely  with  scissors  and  sharp  spoon.  Some  surgeons  prefer,  in  all 
cases  in  which  there  is  exposed  cancerous  grou-th  on  the  cervix,  to 
remove  it  before  commencing  the  operation.  This  procedure  is  based 
on  sound  principles.  Tn  the  removal  of  cancer  elsewhere  in  the  body, 
every  precaution  that  is  possible  is  taken  against  the  reinfection  of  the 
wound  surfaces  by  cancerous  material.  That  raw  surfaces  may  be 
inoculated  in  this  way  is  abundantly  proved  by  clinical  and  experi- 
mental evidence.  Mr.  Herman,  amongst  others,  recommends  that  all 
exposed  growth  should  be  thoi'oughly  scraped  away  with  a  sharp  spoon 
until  firm  tissue  is  reached.  A  Paqueliu's  cautery  is  then  applied  to 
the  whole  surface.  By  this  means  the  chance  of  reinfection  of  the 
operation  wounds  is  greatly  minimised  (I)isea.^es  of  Women,  p.  380). 
In  Dr.  Baldys  Gt/ncecolo'iii  (1894.  p.  389)  it  is  further  recommended 
that  the  funnel-shaped  excavation  made  by  the  spoon  and  cautery  be 
stuffed  with  iodoform  gauze,  and  the  lips  of  the  cavity  sewn  together 
by  means  of  a  continuous  suture. 

Separation  of  Bladder. — It  is  not  a  matter  of  great  importance 
whether  the  surgeon  liegins  by  separating  the  bladder  or  by  opening 
Douglas's  pouch.  If  he  choose  the  former,  the  line  of  reflection  of  the 
bladder  from  the  cervix  is  ascertained  by  passing  a  bladder  sound,  or. 
as  Mr.  Herman  recommends,  by  grasping  the  mucous  membrane  and 
noting  the  line  at  which  you  begin  to  be  able  easily  to  pull  it  from 
the  uterus. 

"With  a  blunt-pointed  pair  of  scissors  the  nmcous  membrane  of  the 
anterior  fornix  is  incised  in  the  median  line  just  below  the  line  of 
reflection  of  the  bladder,  and  the  incision  prolonged  laterally  so  as  to 
surround  the  cervix  in  front.  The  operator  cuts  down  until  the  wall  of 
the  uterus  is  reached,  and  then  proceeds  to  strip  oft'  the  bladder  from  the 
front  of  the  cervix  with  the  fingers,  keeping  close  ag?inst  the  uterus 


564  OPERATIONS  OX  THE  ABDOMEN. 

the  whole  time.  Any  bands  that  resist  separation  by  the  fingers  may 
be  divided  with  scissors.  It  is  most  important  that  this  separation  be 
extended  well  to  the  sides  of  the  uterus,  for  by  doing  so  not  only  is  the 
bladder  saved  from  chance  of  injury  in  the  subsequent  manipulations, 
but  the  ureters  ai'e  pushed  well  out  of  the  way.  The  anterior  peri- 
tonaeum having  been  reached,  is  opened  b}"  pushing  a  sound  or  blunt 
pair  of  forceps  through  it.  or  divided  carefully  with  a  pair  of  scissors, 
the  opening  being  subsequently  enlarged  with  the  fingers.  In  some 
cases,  on  account  of  peri-uterine  inflammation,  difficulty  may  be  experi- 
enced in  separating  the  bladder  from  the  uterus,  and  considerable  risk 
incurred  of  opening  the  former.  Should  this  happen  the  injury  should 
be  at  once  repaired.  If  growth  is  found  to  have  extended  forwards  and 
involved  the  walls  of  the  bladder,  the  operation  had  better  be  dis- 
continued. 

Opening  Douglas's  Pouch. — An  incision  is  next  made  through  the 
mucoiis  membrane  of  the  posterior  fornix,  so  as  to  open  Douglas's 
pouch.  It  is  prolonged  laterally  so  as  to  meet  the  extremities  of  the 
anterior  incision,  care  being  taken  not  to  cut  so  deeply  as  to  wound  the 
uterine  arteries.  There  is  no  fear  of  this,  if  the  incision  at  the  sides  is 
made  through  the  mucous  membrane  only.  In  making  the  posterior 
division  the  cervix  should  be  held  well  forward  by  the  vulsella,  and  the 
points  of  the  scissors  directed  towards  the  uterus  to  avoid  risk  of 
injury  to  the  rectum.  With  care  there  is  no  great  risk  of  this  accident, 
unless  the  posterior  fornix  has  been  much  encroached  on  by  the  growth. 
The  opening  in  the  peritonseum  is  then  prolonged  laterally  with  scissors, 
or,  as  some  prefer,  enlarged  by  tearing  with  the  two  forefingers.  A 
difficulty  met  with  at  this  stage  in  entering  Douglas's  pouch  may  be  due 
to  the  incision  being  carried  through  the  mucous  membrane  only,  and 
the  peritonaeum  separated  and  pushed  before  the  finger.  It  is  un- 
necessary to  pass  a  sponge  through  the  posterior  opening  into  Douglas's 
pouch,  as  recommended  by  some  operators,  unless  actual  protrusion  of 
intestines  takes  place.  Any  bleeding  points  in-  the  cut  edges  of  the 
vagina  should  be  secured  by  pressure-forceps.  A  fear  of  haemorrhage 
occurring  some  hours  after  the  operation  has  led  to  various  modifications 
of  this  part  of  the  operation.  In  Dr.  Bakb^'s  work  (loc.  supra  cif...  p.  389),- 
for  instance,  it  is  recommended  that  the  peritonaeum  be  sewn  to  the  cut 
edge  of  the  vagina  by  a  continuous  catgut  suture ;  and  Dr.  Sinclair 
(Allbutt  and  Playfair,  Syst.  of  Gijn.,  p.  688)  ligatures  the  vaginal  wall 
before  dividing  it.  By  these  proceedings,  the  operation  is  unnecessarily 
complicated,  and  the  possibility  of  haemorrhage  from  this  source  is 
neglected  by  the  majority  of  surgeons. 

The  Management  of  the  Broad  Ligaments. — This  stage  of  the 
operation  is  the  one  that  has  met  with  the  greatest  variety  of  treatment 
at  the  hands  of  different  surgeons ;  and  it  is  not  difficiTlt  to  see  the 
reason  of  this.  The  inconveniences  connected  with  long  silk  ligatures, 
the  dangers  attendant  on  the  use  of  clamps,  the  advantages  or  disad- 
vantages of  closing  the  vaginal  vault  have  influenced  in  various  degrees 
different  operators  in  the  choice  of  one  variety  or  another.  I  will  first 
describe  the  method  of  securing  the  broad  ligaments  by  sutures.  For 
this  purpose  Dr.  Galabin  uses  a  needle  curved  in  a  plane  nearly  at 
right  angles  to  the  handle,  or  two  may  be  used,  curved  respectively  to 
the  right  and  left  for  the  corresponding  broad  ligaments  (Baldy).     Com- 


CANCER  OF  THE  UTERUS. 


565 


mencing  at  the  lower  ])art  of  these  structures,  and  working  first  on  one 
side  then  on  the  other,  successive  portions  are  tied  with  silk  and 
divided.  As  the  division  proceeds,  the  uterus  is  pulled  lower  and  lower, 
first  of  all  the  cervix  and  then  the  body  being  freed  from  its  lateral 
attachments.  Dr.  Galabin  {Dis.  of  Women,  1893,  P-  323)  points  out 
that  "  as  soon  as  the  centre  of  the  uterus  is  divided  from  the  utero- 
sacral  ligaments,  the  fundus  can  generally  be  drawn  down  much  further 
and  the  upper  part  of  the  broad  ligament  brought  within  reach." 

The  tying  of  the  ujDper  part  of  the  broad  ligaments  is  facilitated  by 
seizing  the  fundus  with  vulsella,  retroflexing  it.  and  dragging  it  out 
through  the  posterior  opening  made  into  Douglas's  pouch.  The  body 
may,  however,  be  too  enlarged  to  allow  of  this.      By  this  manipulation 


Fk;.  219. 


Yagiual  hysterectomy  witli  claiups.     (Baldj-.) 
Single-clamp  operation. 

the  upper  parts  of  the  broad  ligaments  are  brought  within  easy  reach, 
and  are  readily  transfixed  by  a  double  ligature  and  tied  in  two  halves. 
If  silk  is  made  use  of  for  the  ligatures,  the  ends  should  be  left  long 
to  facilitate  their  removal.  The  use  of  this  material,  however,  pre- 
sents certain  disadvantages.  If  the  ends  are  left  long,  and  the 
stumps  cannot  be  drawn  do^\■n  and  fixed  in  the  vaginal  roof,  so  as  to 
render  them  extra-peritomeal,  the  silk  strands  serve  as  a  track  along 
which  infection  ma}'  spread  upwards  from  the  vagina.     If  cut  short  and 


\66 


0PERATI0X8  OX  THE  ABDOMEX, 


left  in  the  pelvis,  they  are  veiy  likely  to  serve  as  septic  foreign  iDodies, 
round  which  accnnmlations  of  pus  may  take  place.  In  their  stead  cat- 
gut has  been  recommended  as  being  absorbable,  and,  further,  as  being 
less  likely  to  slip  than  silk.  These  are  cut  short,  whether  left  within 
or  outside  the  peritonieum.  The  objections  to  ligatures,  whether  silk  or 
catgut,  are  these :  they  are  more  difficult  to  apply  than  clamps  and  the 
operation  takes  longer.  Whether  ligatures  or  suitable  clamps,  properly 
applied,  are  the  more  liable  to  slip  is  a  point  difficult  to  decide  ; 
secondary  ha?morrhage  may  result  from  the  use  of  either.  The  greatest 
objection  to  the  ligature  is  the  fact  that,  whatever  precautions  are  taken, 
it  may  serve  as  a  septic  foreign  body.     Xot  even  the  catgut  ligature  is 

Fig.  220. 


Vaginal  liysterectomy  with  clamps.     iBaldj-.) 
^lultiple-clanip  operation  :  tirst  step. 

Iree  from  this  reproach.  A  point  in  favour  of  tying  the  stumps  is  that 
these  latter  can  be  drawn  down  into  the  vaginal  vault,  and  thus  rendered 
entirely,  or  almost  entirely,  extra-peritona?al.  The  method  cif  doing  so 
\\\\\  be  referred  to  later. 

Although  an  equal  number  of  objections  may  be  urgvd  against  the 
use  of  clamps,  I  prefer  this  latter  metliod  of  operating,  largely  on  account 
of  the  greater  ease  and  rapidity  of  procedure. 

Against  their  use  it  has  been  urged  that  they  prevent  closure  of  the 
vaginal  vault,   and  that  the  large  open  channel  thus  left  invites  con- 


CAXCER  OF  THE   UTEEUS. 


567 


tauiination  of  the  pelvic  peritonaeum.  But  this  open  space  provides  such 
free  drainage  that  peritonitis  is  a  very  rare  accident,  and  pelvic  abscess 
is  seldom  seen.  It  is  thought  that  thei"e  is  a  greater  risk  of  including 
the  ureter  in  the  grasp  of  the  forceps,  or  a  danger  of  catching  the 
intestine  in  the  points  of  the  forceps.  This  latter  may  be  avoided  with 
care,  and  the  former  accident  by  freely  separating  and  pushing  aside  the 
soft  parts  at  the  side  of  the  uterus. 

Xumerous  forms  of  forceps  are  employed  for  clamping  the  broad 
ligaments.  The  ones  I  prefer  are  Doyen's,  with  strong  spring  blades, 
which  come  into  close  apposition  when  closed.     Either  one  long  pair 

Fig.  221. 


Yaginal  hysterectomy  with  clamps,    (Ealdy.) 
Multiple-clamp  operation  :  second  step. 


(Fig.  2ig)  may  be  applied  on  each  side,  embracing  the  whole  ligament, 
or  two  or  more  shorter  pairs  may  be  employed  (Figs.  220,  221.  222). 
The  latter  method  is,  I  think,  preferable  to  the  former.  It  is  easier  to 
apply  the  forceps  to  a  half  or  less  of  the  broad  ligament  than  to  the  whole 
of  it ;  there  is  less  risk  of  slipping,  and  as  the  uterus  is  separated  from 
its  attachments  and  brought  lower  down,  there  is  less  risk  of  catching  a 
loop  of  intestine  in  the  ends  of  the  blades.  There  is  less  objection  to 
the  single-clamp  operation  if  the  broad  ligaments  are  short  and  the 
linger  can  readily  be  passed  beyond  them ;  but  when  the}'  are  long  and 


568 


OPERATIONS  OX  THE  ABDOMEN. 


the  upper  border  cannot  be  felt,  the  forceps  should  be  applied  no  farther 
than  the  finger  can  reach,  the  upper  part  of  the  ligament  being  secured 
by  a  second  pair. 

In  applying  the  force2:»s  the  front  and  back  of  the  ligament  are  care- 
fully examined  by  the  finger,  to  make  certain  that  the  bladder  has  been 
well  separated  at  the  sides,  and  that  there  is  no  intestine  in  close 
contiguity.  With  one  finger  in  front  and  another  behind  the  broad 
ligament,  the  two  blades  of  the  forceps  are  guided  into  position,  and 
the  parts  being  again  carefully  examined,  tightened  up.  If  the  entire 
ligament  is   to  be   secured    in   the   grasp   of   one   pair,  they   must   be 

Fig.  222. 


Vagiual  hysterectomy  with  clamps.     (Balcly.) 
Multiple-clamp  operation  :  third  and  final  step. 


passed  beyond  its  upper  border,  and  care  taken  that  no  intestine  is 
included. 

A  similar  proceeding  is  carried  out  on  the  opposite  side.  The  forceps 
having  been  applied,  the  ligament  is  divided  between  the  forceps  and 
the  uterus.  If  the  clamps  have  embraced  a  part  onl}^  of  the  broad 
ligament  on  each  side,  a  second  pair  are  now  applied,  and  the  uterus 
thus  separated  in  successive  portions. 

Closure  of  Vault  of  Vagina. — In  this,  as  in  the  other  stages  of  the 
operation,  practice  varies  widely,  some  surgeons  employing  no  sutures 
at  all,  others  partially  or  entirely  shutting  off  the  peritona3al   cavit}". 


CAXCEIl  OF  THE  UTEEUS. 


569 


Where  silk  lio-atiires  are  emploj'ed  the  stumps  should,  if  possible,  be 
rendered  extra-peritona^al.     This  is  effected  as  follows : — 

B}'  means  of  the  ligatures,  which  have  been  left  long,  the  pedicle  on 
one  side  is  pulled  down  below  the  level  of  the  cut  edge  of  the  vagina  and 
fixed  in  position  by  two  or  three  catgut  sutures.  The  same  proceeding- 
is  carried  out  on  the  opposite  side  (Fig.  223).  By  this  means  the  peri- 
tona?al  cavity  is  almost  entirely  shut  off,  a  small  opening  only  being 
left  in  the  centre  of  the  vault  for  drainage.  Even  this  is  dispensed 
Avith  by  some  surgeons,  the  vaginal  wound  being  completelj^  closed 
by  the  insertion  of  one  or  two  stitches  in  the  median  line  (Fig. 
223).  By  the  employment  of  catgut,  Olshausen  has  been  enabled 
to  completely  close  the  ])eritona?al   cavity,   leaving  the   stumps  in   the 


Fio 


Vaginal  Lysterectomy  with  the  ligature-stumps  drawn  iuto 
the  vagiua,  with  sutui-es  in  place  readj*  to  close  tlie  opening  in 
the  vaginal  vault.     (Baldj-.) 


l^elvis.  The  gut  ligatures  are  cut  short  and  the  i)edicles  allowed  to 
retract  within  the  periton;eal  sac.  The  wound  is  then  closed  by 
sutures  ])assed  from  before  backwards  through  the  edges  of  the  anterior 
vaginal  wall,  the  auterioi-  layer  of  peritonjipum,  the  i)Osterior  peritonivum, 
and  the  posterior  wall  of  vagina.  His  success  has  not  been  obtained  by 
everyone  who  has  followed  his  methods.  Dr.  Sinclair  (loc.  siqn-a  cit., 
]).  690)  says  :  ••  After  Olshausen's  success  in  completing  the  operation  by 
cutting  short  the  broad  ligament  ligatures,  and  completely  closing  the 
wound  in  the  pelvis,  I  tried  for  a  time  to  do  without  drainage,  but 
found  the  result  unsatisfactor}-.  Several  times,  owing  to  unfavourable 
.symptoms  which  followed,  it  was  necessar}-  to  undo  some  stitches  in 
order  to  permit  of  the  escape  of  retained  fluid."'     Considering  the  diffi- 


570  OPERATIONS  ON  THE  AP,D03IEX. 

culties  of  cleansing  the  vagina,  there  must  ahvaj'S  be  some  risk  of 
infection  during  the  operation,  and  it  appears  on  the  whole  safer  to 
provide  for  drainage  of  the  pelvic  pouch,  especially  when  ligatures  are 
left  within  it.  When  forceps  are  employed  the  stumps  cannot  be  rendered 
extra-peritonaeal.  If  at  the  time  of  operation  there  appeared  to  be  a 
tendency  to  prolapse  of  the  intestines,  a  stitch  or  two  might  be  inserted 
in  the  centre  of  the  vaginal  roof;  but  otherwise  they  are  not  necessary. 
After-treatment. — After  the  removal  of  the  uterus,  the  vagina  is 
loosely  packed  with  a  strip  of  iodoform  gauze,  and  if  forceps  are  used 
the  gauze  should  be  wrapped  round  their  handles  where  they  lie  in  con- 
tact with  the  vulva.  The  forceps  are  removed  at  the  end  of  thirty-six 
hours,  and  the  plug  of  gauze  renewed.  When  sutures  are  employed 
the  gauze  ping  may  be  left  in  three  or  four  days.  It  is  better  not  to 
employ  a  douche  for  the  first  five  or  six  days,  though,  if  carefull}'  given 
by  the  surgeon  himself,  there  is  not  much  danger  in  its  iise  after  the 
second  da}'. 


CJESARIAN   SECTION. 

Indications. — (i)  An  extreme  degree  of  pelvic  contraction,  when 
the  smallest  diameter  through  which  the  child  lias  to  pass  is  less  than 
two  inches. 

(2)  Solid  tumours  of  the  pelvis  or  uterus,  which  cannot  he  pushed 
out  of  the  wa}- ;  cancer  of  the  cervix  and  cicatricial  contraction  of  the 
passages. 

(3)  In  any  case  in  which  there  is  no  hope  of  obtaining  a  living- 
child,  even  by  the  induction  of  premature  labour,  it  is  reasonable  to 
offer  the  mother  the  option  of  undergoing  a  somewhat  greater  risk  to 
save  the  life  of  the  child  (Dr.  Galabin,  Manual  of  Midwifenj).  Under 
these  circumstances,  Caesarian  section  further  offers  the  great  advantage 
that  the  patient  can  be  sterilised  by  resection  or  removal  of  the  Fallopian 
tubes,  if  the  conditions  causing  obstruction  are  permanent  ones. 

Time  of  Operating. — There  are  three  possibilities  :  (i)  To  wait  until 
labour  comes  on  spontaneoush\  (2)  To  operate  at  a  certain  fixed  time 
before  the  commencement  of  labour  pains.  (3)  To  induce  labour  by 
the  passage  of  a  bougie  and  operate  at  a  pre-arranged  time. 

The  great  objection  to  waiting  for  the  onset  of  natural  labour  is  that 
the  operation  may  have  to  be  performed  at  night,  often  without  the 
necessar}-  assistance  and  with  the  ]:)atient  imperfectly  prepared.  For 
these  reasons  many  surgeons  prefer  to  operate  at  a  definite  time,  which 
is  arranged  for  a  few  days  before  full  term.  This  is  undoiibtedly 
the  most  satisfactory  plan.  The  operation  can  be  undertaken  in  day- 
light, the  needful  assistance  is  forthcoming,  and  the  patient  can  undergo 
the  proper  preliminary  treatihent — as  necessary  in  Cassarian  section  as 
for  any  other  abdominal  operation.  The  chief  objection  made  to 
operating  before  the  onset  of  labour  is  that  the  uterus  may  not  contract 
well,  with  the  risk  of  haemorrhage  that  imperfect  contraction  entails. 
Practical  experience  has,  however,  shown  that  the  fear  of  uterine 
inertia  and  bleeding  is  unfounded.  If  the  surgeon  jn'efers  to 
operate  after  labour  pains  have  commenced,  he  may  still  do  so  at  a  pre- 
arranged time  by  passing  a  bougie  over-night.     It  is  possible  that  the 


1 


C.ESARIAX  SECTIOX.  57 1 

pains  may  not  come  on  by  the  time  arranged.  Under  tliese  circum- 
stances he  must  either  defer  his  operation  until  the\'  appear,  ^^•hich  may 
be  at  a  most  unsuitable  time,  or  operate  without  pains.  The  latter 
alternative  is  the  better  one.  Dr.  Kellj'"  saj'S  that  he  has  met  with  no 
such  accident  as  the  failure  of  the  uterus  to  contract  and  haemon'hage 
as  the  result  of  operating  without  waiting  for  the  pains  to  come  on 
(loc.  ffup-a  cit.,  vol.  ii.  p.  417). 

Operation. — The  patient  is  pi'epared  as  for  ovariotomy,  attention 
being  paid  to  the  diet,  the  regulation  of  the  bowels  and  the  points 
previousl}'  mentioned.  The  abdomen  is  thoroiighly  cleansed,  and  the 
vagina  douched  with  i-iooo  sublimate  solution  or  other  antiseptic. 
There  should  be  two  assistants  in  addition  to  the  anaesthetist,  one  to 
stand  opposite  the  surgeon  and  assist  in  the  various  mani])ulations,  the 
other  to  hand  instruments,  whilst  someone,  in  addition,  should  be 
present  who  is  competent  to  attend  to  the  child  when  delivered. 

Abdominal  Incision. — The  incision  through  the  abdominal  wall 
should  be  six  inches  long,  of  which  about  a  third  will  be  above  the 
umbilicus,  whilst  the  lo\\er  end  should  not  be  nearer  than  two  or 
three  inches  to  the  pubes.  The  incision  is  made  deliberately  in  the 
median  line,  as  already  described  in  the  operation  for  ovariotomy,  all 
bleeding  points  being  carefully  arrested.  The  peritonasum,  being 
reached,  is  picked  up  and  opened,  and  then  divided  on  the  fingers  for 
the  full  length  of  the  skin  incision.  In  dividing  this  structure  down- 
wards towards  the  pubes,  the  fingers,  used  as  directors,  will  serve  to 
detect  the  bladder  if  this  is  much  drawn  up — a  complication  most  likely 
to  be  found  when  labour  has  been  protracted.  It  has  been  the  custom 
to  employ  the  rubber  tube  introduced  by  Milller  to  control  hasmorrhage 
from  the  uterus  during  the  operation.  This  tube,  which  is  about  a  yard 
long,  is  passed  over  the  fundus  of  the  uterus  and  adjusted  round  its 
lower  segment.  By  its  employment  the  loss  of  blood  during  the  opera- 
tion is  very  slight,  and  the  surgeon  may  be  as  deliberate  as  he  pleases. 
If  applied  for  too  long  it  has  the  grave  disadvantage  of  producing 
uterine  inertia  and  hgemorrhage  from  interference  with  the  blood-supply 
to  the  muscle.  When  competent  assistance  is  at  hand,  the  operator 
will,  therefore,  do  well  to  discard  it,  and  trust,  if  ha?morrhage  is  severe, 
to  compression  by  the  assistant's  hands  of  the  broad  ligaments  against 
the  lower  iiterine  segment.  If  good  assistance  is  not  obtainable,  it  may 
be  thrown  round  the  uterus  as  a  precautionary  measure,  to  be  employed 
if  necessity  arises.  The  next  step  is  the  opening  of  the  uterus,  and  this 
and  the  following  stages  in  the  operation  should  be  performed  as 
rapidly  as  possible. 

Incision  of  Uterus. — The  assistant  should,  as  recommended  by  ]Mr. 
Herman,  ])lace  a  hand  on  each  side  of  the  abdominal  wall,  and  press  it 
down^\•ards  and  backwards,  so  as  to  make  the  wound  gape  and  prevent  fluid 
entering  the  peritonteal  cavit}'.  The  surgeon  cuts  through  the  uterine  wall 
at  one  spot  till  the  membranes  are  reached,  and  then  rapidly  enlarges 
the  incision  up  and  down  till  it  is  nearly  the  length  of  the  abdominal 
incision,  that  is,  nearly  six  inches  long.  If  the  placenta  is  beneath  the 
incision  it  is  usually  recommended  that  it  be  cut  through.  Dr.  Kelly 
thinks  this  a  mistake,  and  reconunends  that  the  nearest  border  be 
sought  for  and  the  membranes  opened  there.  Hannorrhage  is  usually 
moderate,  unless  the  placenta  is  attached  to  the  anterior  wall.     If  from 


572  OPERATIONS  ON  THE  ABDOMEN. 

this  cause  the  bleeding  is  alarming,  it  should  be  controlled  by  an 
assistant  grasping  the  lower  pai^t  of  the  uterus  and  compressing  the 
broad  ligaments,  or  by  tightening  the  elastic  ligature  if  this  has  been 
previously  applied. 

Extraction  of  Child. — The  uterus  having  been  opened,  the  surgeon 
introduces  a  hand  and  seizes  a  knee  or  foot  and  delivers  the  child.  It 
has  been  recommended,  on  account  of  occasional  trouble  in  the  extraction 
of  the  after-coming  head,  that  this  should  be  delivered  first.  It  is  not, 
however,  easy  to  grasp,  and  will  probably  require  both  hands,  which 
take  up  more  room  than  is  convenient  in  the  uterine  wound.  Difficulty 
in  extraction  of  the  head  is  generally  due  to  too  small  an  incision  in 
the  uterine  wall.  The  child  having  Ijeen  delivered,  the  funis  is  tied 
and  divided,  or  time  may  be  saved  by  clamping  it  temporarily  and 
tying  the  foetal  end  after  division.  After  the  removal  of  the  child,  the 
uterus,  being  sufficiently  diminished  in  size,  is  brought  out  through  the 
abdominal  wound,  and  a  large  flat  sponge  or  gauze  swab  placed  behind  it. 
If  the  elastic  ligature  is  employed,  it  ma}'  now  be  tightened  up,  but,  on 
account  of  the  objections  given  above,  its  use  is  not  recommended  under 
ordinarA^  circumstances,  compression  by  the  assistant's  hands  being 
employed  instead.  The  placenta  and  membranes  are  then  carefully 
peeled  off  the  uterine  wall  and  I'emoved,  and  the  interior  of  the  uterus 
mopped  over  with  i-iooo  sublimate  solution.  If  the  uterus  does  not 
contract  readily,  it  should  be  stimulated  to  do  so  by  compression. 

Uterine  Sutures. — Silk  is  the  best  material  to  use  for  this  purpose, 
and  both  deep  and  superficial  sutures  should  be  employed.  Of  the 
deep,  about  ten  should  be  inserted  about  half  an  inch  or  rather  more 
apart.  They  are  introduced  half  an  inch  from  the  edge  of  the  wound 
on  a  half-curved  or  fullj^-curved  needle,  and  are  brought  out  on  the  cut 
surface  close  to,  but  not  including,  the  decidual  surface  of  tiie  uterus. 
For  the  superficial  ones  Lembert's  suture  is  made  use  of,  fine  silk  being 
introduced  one-third  of  an  inch  from  the  cut  edge  of  the  peritonaeum 
and  brought  out  again  close  to  the  edge,  the  reverse  procedure  being 
adopted  on  the  opposite  side.  When  the  sutures  are  tied,  the  two  edges 
of  peritonaeum  are  tiu-ned  in,  and  are  in  apposition  along  the  line  of 
incision. 

Sterilisation  of  Patient.^ — ^If  the  condition  requiring  Caesarian 
section  is  one  which  cannot  be  remedied,  and  the  patient  runs  the 
risk  of  a  subsequent  pregnancy,  she  should  be  sterilised.  This  is  done 
by  removing  as  much  as  possible  of  the  Fallopian  tube. 

The  tube  being  picked  up,  a  double  ligature,  threaded  on  a  pedicle 
needle,  is  passed  through  the  broad  ligament  a  sufficient  distance  below 
it.  The  loop  having  been  divided,  the  two  strands  are  interlocked,  and 
one  is  tied  round  the  tube  close  to  its  uterine  end,  whilst  the  other  is 
tied  round  the  free  edge  of  the  broad  ligament  beyond  the  fimbriated 
extremity.  The  ovary  should  not  be  included  in  the  ligature,  which 
should  be  carried  between  it  and  the  Fallopian  tube.  The  tube  is  then 
cut  away  between  the  two  ligatures. 

The  subsequent  stages  of  the  operation  and  the  after-treatment  are 
similar  to  those  described  in  the  operation  of  ovariotomy. 


POREOS    OPERATIOX.  575 


PORRO'S    OPERATION". 


Porro's  modification  of  Ca3sarian  section  consists  in  supra-vaginal 
amputation  of  the  uterus  and  fixation  of  the  stump  in  the  lower  ang-le 
of  the  wound.  But  under  this  heading  are  now  included  partial 
hysterectomy  with  intra-peritonseal  treatment  of  the  stump  and  total 
hysterectomy. 

The  simplest  method,  and  the  one  best  adapted  for  those  inexperienced 
in  abdominal  surgery,  is  the  operation  devised  by  Porro.  It  has  received 
various  modifications,  and  that  described  by  Mr.  Herman  (DijficnJt 
Labour)  after  the  method  of  the  late  Mr.  Lawson  Tait,  may  be  regarded 
as  the  best  on  account  of  the  simplicity  of  its  details  and  tlie  few 
instruments  required. 

The  abdomen  having  been  opened,  as  described  in  Caesarian  section. 
a  rubber  tube,  two  feet  long,  is  slipped  over  the  fundus  and  adjusted 
round  the  lower  part  of  the  iiterus.  The  ends  of  the  tube  are  tied  in  a 
single  hitch,  and  prevented  from  slipping  by  being  grasped  in  a  pair 
of  forceps.  The  uterus  is  then  opened  at  one  point,  and  the  incision 
enlarged  by  tearing  with  the  fingers.  The  child  is  then  extracted. 
The  uterus  is  now  brought  out  of  the  abdomen,  the  ligature  tightened 
if  necessary  and  tied  a  second  time.  Two  knitting  needles  are  passed 
from  side  to  side  through  the  flattened  rubber  tube  and  the  cervix,  and 
the  uterus  cut  off  about  three-quarters  of  an  inch  above  the  needles. 
The  abdominal  wound  is  sewn  up  with  interrupted  silkworm  gut 
sutures  about  two-thirds  of  an  inch  apart,  the  lowest  stitch  being  passed 
throiigh  the  stump  below  the  elastic  ligature,  as  well  as  through  the 
abdominal  wall.  The  stump  is  dressed  with  iodoform  and  tannic  acid 
powder,  and  covered  with  a  layer  of  diy  dressing. 

This  operation  carries  with  it  the  risks  and  disadvantages  already 
mentioned  in  the  section  on  hysterectomy,  and  the  expert  operator  will 
prefer,  after  removing  the  uterus,  to  treat  the  stump  by  the  intra- 
peritonteal  method.  The  details  of  this  operation  are  similar  to  those 
mentioned  above  in  the  removal  of  the  uterus  for  fibroids. 

Indications  for  the  operation  are  as  follows  : — 

1.  Failure  of  the  uterus  to  contract  after  removal  of  the  child. 

2.  Injuries  to  the  uterus  sustained  in  efforts  to  deliver  through  the 
pelvis,  such  as  rupture. 

3.  The  fact  that  the  operator  is  inexperienced.  In  this  case  he 
should  adopt  the  method  of  amputation  with  fixation  of  the  stump 
in  the  abdominal  wound,  as  described  above. 

Removal  of  the  iiterus  may  be  indicated  in  the  radical  treatment  of 
the  condition  aivino-  rise  to  the  obstruction.  This  gives  such  further 
indications  as  follows  : — 

4.  When  the  uterus  contains  myomatous  tumours  which  block  the 
pelvis,  or  which  cannot  safely  be  removed  b}^  myomectomy  (Kelly). 

5.  When  there  are  bilateral  ovarian  tumours,  and  no  sound  part  of  an 
ovary  can  be  found  and  left  (Kelly). 

6.  When  the  patient  is  suffering  from  osteo-malacia  (Herman).  The 
removal  of  the  ovaries  has  been  found  to  have  a  curative  effect  on 
this  disease.  In  the  two  latter  conditions  the  uterus  is  removed,  as  it  is 
no  longer  of  use  to  the  patient  after  the  ovaries  have  been  taken  away. 


574  OPERATIONS  ON  THE  ABD03IEN. 

7.  When  there  is  cancer  of  the  cervix  (Kelly).  If  this  condition 
is  found  to  exist,  and  hysterectomy  is  decided  on,  the  whole  uterus 
must  be  removed. 


ECTOPIC    GESTATION. 

From  the  jjoint  of  view  of  treatment  cases  of  extra-uterine  g-estation 
are  best  considered  under  three  headings  :  (i)  Before  rupture  has  taken 
place;  (2)  at  the  time  of  rupture  ;  (3)  after  rupture. 

1.  Cases  in  which  the  Tube  is  Unruptured. 

As  rupture  of  the  tube  almost  invariably  occurs  before  the  tenth 
week,  this  class  may  be  held  to  include  cases  of  extra-uterine  o'estation 
up  to  two  and  a-half  months.  It  is  rarely,  however,  that  the  condition 
is  diagnosed,  and  after  diagnosis  it  is  not  unlikely  that  the  condition 
may  be  found  to  be  one  of  hydro-  or  pyo-salpinx.  If  there  is  any 
suspicion  that  a  tubal  pregnancv  exists,  the  patient  should  submit  to 
operation  at  once.  Delay  means  the  risk  cif  rupture  and  severe  or  fatal 
hsemorrhage.  The  operation  is  practically  identical  with  that  described 
for  removal  of  the  appendages.  Adhesions  are  recent,  and  do  not  give 
rise  to  much  trouble.  Care  must  be  taken  not  to  rupture  the  sac  in  the 
separation  of  adhesions  or  in  drawing  it  up  into  the  wound  for  the 
])urpose  of  ligaturing  the  broad  ligament.  Should  severe  haemorrhage 
from  this  cause  occur,  it  should  be  controlled  l3y  cjuickly  appljdng  the 
ligatures  to  the  pedicle,  or  by  controlling  the  blood-supjil}^  at  the  uterine 
cornu  and  the  brim  of  the  pelvis. 

2.  Tubal  Abortion  or  Rupture. 

The  condition  most  often  calling  for  operative  measures  is  the  result 
of  rupture  of  the  tube,  or  abortion.  Rupture  may  take  place  either  into 
the  perit()na?al  cavity  or  between  the  layers  of  the  broad  ligament.  It 
more  often  happens,  however,  that  haemorrhage  takes  place  into  the 
foetal  membranes,  with  the  production  of  a  mole,  and  this  is  expelled 
in  whole  or  in  part  through  the  dilated  ostium  of  the  Fallopian  tube 
into  the  peritonaeal  sac.  This  event,  which  is  known  as  tubal  abortion, 
is  accompanied  by  hemorrhage.  Though  likely  to  be  continuous  or 
frequently  repeated,  the  bleeding  is  much  more  moderate  in  amount 
as  a  rule  than  that  following  a  rupture,  which  is  often  jirofuse  and 
attended  with  grave  danger  to  life. 

Should  an  operation  be  performed  in  all  cases  in  which  this  accident 
is  diagnosed  ?  We  know  that  many  cases  get  well  if  left  alone,  though 
N\hat  proportion  they  bear  to  those  requiring  operation  we  cannot  at 
present  say.  A  patient  occasionally  dies  of  haemorrhage  before  assist- 
ance can  be  obtained,  whilst  in  many  instances,  on  the  other  hand,  the 
initial  symptoms  are  so  slight  that  the  patient  pays  but  little  attention 
to  them,  and  it  is  only  on  account  of  a  persistence  or  a  recurrence  of 
pain  that  a  surgeon  is  called  in,  perhaps  weeks  after  the  onset.  When 
the  symptoms  are  so  grave  that  life  is  threatened,  there  can  be  no  doubt 
as  to  the  advisability  of  immediate  o])eration.  But  if  the  patient  is 
recovering  when  first  seen,  and  the  collapse  and  signs  of  hnemorrhage 
are  not  severe,  the  indications  are  less  clear.  There  is  no  doubt  that 
in  most  cases  no  ill  results  will  follow  from  delay  for  a  time.  But 
though  the  initial  bleeding  is  slight,  it  may  recur  later  with  greater 


ECTOPIC  GESTATIOX.  575 

severity,  and  the  clanger  of  temj^orising  in  any  recent  case  should  (.011- 
sequently  be  fully  recognised.  If  a  diagnosis  of  rupture  into  a  broad 
ligament  can  be  made,  it  is  perfectly  justifiable  to  wait  awhile,  as  the 
ha?morrhage  will,  in  all  probability,  soon  cease,  and  the  htematocele  can. 
if  necessity  arises,  be  dealt  with  later  by  drainage. 

The  Operation. — An  incision,  four  to  five  inches  long,  is  made  in  the 
median  line  and  carried  well  down  to  the  pnbes.  If  the  case  is  a  severe 
one,  blood  may  at  once  escape  from  the  abdomen  when  the  peritona?um 
is  opened.  This  is  moj)ped  and  scooped  out  as  rapidly  as  possible,  and 
if  it  appears  that  haemorrhage  is  continuing,  no  attempt  should  be  made 
to  cleanse  the  peritona?al  sac.  l)ut  the  bleeding  controlled  at  once.  This 
is  done  by  identifying  the  fundus  and  tracing  the  affected  tube  outwards 
from  this.  The  sac  is  dra\\'n  up  towards  the  wound,  and  a  pair  of  Spencer 
Wells's  forceps  are  applied  to  the  uterine  end  of  the  tube,  so  as  to  include 
m  its  grasp  the  terminal  branches  of  the  uterine  artery,  and  a  second 
pair  to  the  broad  ligament  at  the  brim  of  the  pelvis  to  secure  the 
ovarian  artery.  The  abdomen  can  then  be  cleansed  by  means  of  sponges 
or  by  washing  out  with  warm  water,  and  the  parts  inspected.  The  tube 
is  then  brought  up  into  the  wound  and  ligatures  applied,  as  described 
in  the  section  on  the  removal  of  the  appendages. 

3.  After  Rupture  of  Sac. 

In  the  majority  of  cases,  fortunately,  the  foetus  is  destroyed  in  the 
early  months  of  pregnancy,  either  in  the  tube  or  after  its  escape  into 
the  abdominal  cavity  or  lietween  the  layers  of  the  broad  ligament. 
Treatment  then  resolves  itself  into  dealing  with  a  collection  of  blood 
in  the  pelvis,  either  shut  off  by  adhesions  and  matted  viscera  from  the 
general  peritonjeal  cavity,  or  lying  between  the  layers  of  the  broad 
ligament.  If  there  is  no  evidence  that  bleeding  is  recurring,  the 
patient  should  be  treated  by  rest,  in  the  hopes  that  the  htematocele 
Avill  subside. 

If  on  account  of  recurrent  attacks  of  pain  and  marked  anaemia  there 
is  reason  to  suspect  repeated  haemorrhages,  abdominal  section  should 
be  performed  and  the  tube  removed.  This  will  differ  from  the  operation 
undertaken  at  the  time  of  rupture  in  that  the  tube  and  blood-clot  ^^'ill 
be  found  enclosed  by  adhesions  and  matted  bowel  and  omentum.  These 
latter  must  be  carefully  separated  until  the  sac  and  surrounding  blood- 
clot  are  brought  into  view.  The  tube. is  then  dealt  with  as  previouslv 
described. 

If  there  are  no  signs  of  fresh  bleeding,  and  the  ha?matocele,  which 
is  bulging  down  Douglas's  pouch,  shows  little  tendency  to  diminish  in 
size  as  the  result  of  rest,  it  should  be  treated  by  drainage  through  the 
vagina.  When  rupture  has  taken  place  into  the  broad  ligament,  Dr. 
Kelly  (loc.  supra  cit..  vol.  ii.  p.  456)  considers  that  the  proper  treatment 
is  to  evacuate  and  drain  the  sac  extra-peritouieally,  either  by  the  vagina 
or  above  Poupart's  ligament.  It  should  be  opened  in  the  latter  situation 
when  "the  sac  elevates  the  peritonaeum  of  the  anterior  abdominal  wall, 
so  as  to  be  easily  accessible  from  the  front." 

If  the  foetus  survives,  the  dangers  of  operation  increase  as  pregnancy 
advances,  and  no  time  should  be  lost  in  arranging  for  as  earlv  an 
operation  as  possible.  The  great  difficulty  that  the  surgeon  has  to 
contend  with  is  the  treatment  of  the  placenta.  This  organ  and  its 
site  are  certain  to  bleed  very  freely  at  the  operation  if  any  detachment 


576  OPERATIONS  ON  THE  ABDOMEN. 

occurs  ;  and  if  the  placenta,  is  left  behind  in  the  sac  there  is  the 
greatest  possible  risk  of  septic  absorption. 

If  the  incision  in  the  abdominal  wall  can  be  made  so  as  to  avoid  this 
organ,  whose  position  may  be  sometimes  recognised  by  palpation  (never 
by  auscultation,  and  this  must  be  remembered,  since  many  authors 
wrongly  state  that  the  situation  of  the  placenta  can  be  ascertained  by 
means  of  the  uterine  bruit)  so  much  the  better.  Tiie  best  place  to 
choose  is  where  the  foetal  outlines  can  be  most  plainly  felt.  The  sac 
should  be  opened  ex h-a-periton really  if  possible.  The  child  is  extracted, 
and  a  clamp  put  on  the  cord,  which  is  divided  on  the  maternal  side  of 
the  clip.  If  there  is  an}^  possibility  of  completely  removing  the  sac  this 
should  be  carefully  considered,  as  by  such  a  procedure  much  of  the 
difficulty  afterwards  is  removed.  It  is,  however,  scarcely  ever  possible 
to  do  so,  and  the  sac  must  be  stitched  to  the  edges  of  the  abdominal 
wound.  The  blood  should  be  allowed  to  escape  as  completely  as  possible 
from  the  placenta  through  the  divided  vessels  of  the  cord,  and  if  the 
placenta  cannot  be  safely  sti'ipped  off  the  sac-wall  it  must  be  left 
behind,  and  the  cord  should  be  cut  short  off.  The  sac  is  then  plugged 
with  strips  of  gauze  during  the  time  that  the  placenta  is  being  expelled. 
The  opening  must  be  carefully  watched  and  not  allowed  to  close,  and  no 
accumulation  of  fluid  is  to  be  permitted. 

If  the  child  has  been  dead  for  some  weeks  at  the  time  of  operation, 
and  the  circulation  through  the  placenta  has  dwindled  considerably,  it 
may  not  be  difficult  to  remove  the  placenta  without  much  bloodshed, 
and  this  should  always  be  attempted;  if  it  cannot  be  done,  the  case  must 
be  treated  in  the  way  just  described. 


CHAPTER   XYIII. 
SACRO-ILIAC    DISEASE. 

ARTHRECTOMY. 

It  has  been  shown  that  the  prognosis  in  this  disease,  usually  looked 
iipon  as  so  grave,  is  much  better  if  the  same  radical  methods  of  treat- 
ment, which  have  proved  so  satisfactor}'  in  other  joints,  are  applied  to 
the  sacro-iliac  synchondrosis. 

Mr.  Collier  first  drew  attention  to  the  above  fact  with  a  case  success- 
fully treated  by  trephining  (Lancet,  1889,  vol.  ii,  p.  787),  and  Mr. 
Makins  and  Mr.  Golding  Bird  followed,  each  surgeon  publishing  three 
successful  cases  (Clin.  Soc.  Trans.,  vol.  xxvi.  p.  127,  and  vol.  xxviii. 
p.  186).     The  following  points  are  taken  from  these  papers  : 

Operation. — The  joint  is  exposed  by  a  crucial  incision  (Makins),  or 
by  a  flap  (Collier,  Golding  Bird).  In  the  words  of  the  last-named 
siirgeon,  "  a  semicircular  flap  of  skin  and  subcutaneous  tissue  over  the 
iliac  area  of  the  joint,  and  ha\ang  its  convexity  corresponding  to  the 
posterior  edge  of  the  ilium  is  dissected  upwards  and  forwards,  and  the 
underlying  gluttei  are  detached.  The  bone  being  thus  freely  exposed,  a 
large  trephine  is  applied  at  the  root  of  the  posterior  inferior  iliac  spine, 
and  in  a  line  drawn  from  the  top  of  that  spine  to  the  junction   of  the 

anterior  with  the  middle  third  of  the  iliac  crest The  ilium  at  the 

seat  of  operation  is  very  thick,  but  the  disc  of  bone  removed  should 
reach  quite  down  to  the  joint."  The  trephine-opening  is  then  suffi- 
ciently enlarged,  the  articular  surfaces  cut  away  with  a  gouge  or  forceps 
suflBciently  to  enable  the  surgeon  to  explore  the  pelvic  surface  of  the 
joint,  and  to  liberate  any  pus  Ij'ing  on  this  aspect.  The  sharp  spoon,  or 
Barker's  flushing  gouge  (p.  601)  is  then  thoroughly  used,  all  frag- 
ments of  bone,  granulation  tissue,  or  loosened  cartilage  removed,  and 
any  sinuses  present  laid  open.  Sterilised  iodoform  having  been  next 
applied,  the  soft  parts  ai'e  lightly  drawn  together  with  a  few  sutures.  A 
long  outside,  or  a  Thomas's  hip-splint,  should  be  used  at  first,  but 
subsequently,  all  that  is  needed  is  a  well-fitting  pelvic  belt,  as  advised 
by  Mr.  Hilton. 


VOL.  II.  37 


PART    V. 
OPERATIONS   ON   THE   LOWER   EXTREMITY. 

CHAPTER   I. 
OPERATIONS   ON   THE   HIP-JOINT. 

AMPUTATION    AT    THE    HIP-JOINT.     EXCISION    OF 
THE    HIP-JOINT. 

AMPUTATION    AT    THE    HIP-JOINT    (Figs.   224-233). 

This  formidable  operation  has  been  mncli  simplified  of  late  years  by  the 
most  important  improvement  of  Mr.  Furneaux  Jordan,*  whose  method 
should  replace  all  others  in  every  possible  case.  It  will  be  described 
first  here,  and  a  few  of  the  other  methods,  sufficient  for  all  j)ractical 
purposes,  will  be  given  afterwards. 


*  Dr.  W.  E.  Arnold,  assistant-surgeon  U.S.  Navy,  has  kindly  drawn  my  attention  to 
the  fact  that  an  amputation,  in  all  essentials  the  same  as  Furneaux  Jordan's,  was 
performed  as  long  ago  as  1806  by  Dr.  W.  Brashear  in  Bardstown,  Kentucky.  The 
following  account  taken  from  a  letter  by  Dr.  Brashear  will  be  found  in  Dr.  Mott's 
edition  of  Velpeau's  Surgery,  in  a  summary  of  hip-joint  amputations  by  Dr.  Eve,  of 
Tennessee.  The  patient  was  a  lad,  aged  17.  An  operation  on  the  thigh  in  the 
ordinary  manner  was  determined  upon,  as  remote  from  the  hip-joint  as  cii'cumstances 
might  justify  (in  this  case,  about  mid-thigh).  The  amputation  was  performed  and  the 
arteries  secured.  The  great  step  was  to  make  an  incision  to  and  from  the  lower  end  of 
the  bone  externally  over  the  great  trochanter,  to  the  head  of  the  bone  and  upper  part 
of  the  socket.  The  dissection  of  the  bone  from  the  surrounding  muscles  was  simple  and 
safe,  by  keeping  the  edge  of  the  knife  resting  against  it.  The  bone  being  disengaged 
from  its  integuments  at  its  lower  extremity,  was  then  turned  out  at  a  right  angle  from 
the  body,  so  as  to  give  every  facility  in  the  operation  to  separate  the  capsular  ligament 
and  remove  the  head  from  its  socket.  The  patient  made  a  good  recovery.  Judging 
from  a  letter  from  Prof.  Oilier  to  Mr.  Shuter  (loc.  infra  cit.)  the  former  surgeon  had 
recommended  this  method  in  1859,  and  performed  such  an  operation  once. 


AMPUTATION  AT  THE   Hir-JOIXT.  579 

Methods. — I.  Furneaux  Jordan.  II.  Antero-posterior  Flaps. 
III.  Lateral  Flaps.  I\'.  Modified  Lateral — viz.,  Antero-internal 
and  Postero-external — Flaps. 

I.  Furneaux  Jordan's  Method  (Fig.  226). — By  amjDutating  through 
the  thigh  as  low  down  as  possible,  and  shelling  out  and  disarticulating 
the  femur,  it  is  now  possible  to  avoid,  in  large  measure,  those  dangers 
which  were  formerly  inseparable  from  the  operation — viz.  :  i.  Shock, 
the  limb  being  removed  much  farther  from  the  trunk.  2.  Haemorrhage. 
a.  Abundant  room  is  afforded  for  compression  of  the  common  femoral, 
and  the  vessels  behind.  l>.  The  large  vessels  can  easily  be  secured  on 
the  face  of  the  stump,  c.  The  gluteal  and  sciatic  arteries  remain  un- 
touched, the  haemorrhage  from  these,  in  the  older  operations,  being  a 
source  of  serious  danger.  3.  Septic  changes.  By  the  other  methods, 
the  copious  discharge  of  bloody  serum  from  the  large  wound,*  being 
poured  out  close  to  the  anus  and  genitals,  was  very  liable  to  infection. 
By  this  operation,  both  the  end  of  the  stump  and  the  wound  on  the 
outer  side  can  be  more  easily  drained  and  kept  aseptic.  In  making  use 
of  this  amputation,  especially  for  hip  disease  or  failed  excision,  the 
surgeon  should  not  attempt  too  much  to  secure  primary  union,  f  4. 
The  stump  is  a  better  one.  It  is  longer,  more  mobile,  and  occasionally, 
as  in  amputation  for  acute  periostitis  or  necrosis,  it  is  possible  to  pre- 
serve much  of  the  periosteum  from  the  upper  half  of  the  femur,  and  a 
cord  X  will  be  left  which  will  render  the  stump  movable.  Whether  in 
any  case  an  artificial  limb  can  be  worn  for  more  than  about  half  an 
hour  at  a  time  is  very  doubtful. 

Methods  of  Controlling  Haemorrhage  during  Amputation  at  the 
Hip-Joint. 

I.  Elastic  Compression  hy  Jordan  Lloijd'^  Metliod  (Fig.  226). — This 
may  be  applied  at  the  junction  of  the  limb  and  trunk,  without  inter- 

*  As  will  be  shown  below,  the  wound  in  a  Furneaux  .Jordan  amputation  is  also  a 
large  one,  but  much  more  happily  placed  for  being  drained  and  kept  sweet. 

f  Verneuil  (^Paris  Acad,  de  Jled..  1877). 

X  The  committee  of  the  Clinical  Society  appointed  to  examine  Mr.  Shuter's  case  of 
6ub-periosteal  amputation  of  the  hip-joint  reported  (^Trann.,  vol.  xvi.  p.  8g),  (i)  that, 
though  there  was  a  firm,  resisting  cord  of  considerable  size  in  the  centre,  which  afforded 
the  muscles  a  common  point  of  attachment,  there  was  not  sufiicient  evidence  to  enable 
them  to  state  that  this  cord  contained  bone  ;  (2)  that  the  muscles  were  in  a  high  state 
of  nutrition,  the  patient  not  only  powerfully  flexing,  extending,  abducting,  and  ad- 
ducting  his  stump,  but  being  able  to  communicate  all  these  movements  to  the  artificial 
limb. 

Mr.  Shuter  in  his  paper  (loc.  supra  cit.^  says  that  his  patient  was  able  to  wear  an 
artificial  limb  "  for  some  hours  nearly  every  day  for  a  period  of  about  five  months. 
I  then  forbad  his  wearing  it  for  a  time  on  account  of  a  tender  sinus  which  opened 
opposite  to  the  acetabulum."  In  the  notes  of  this  case,  quoted  by  Mr.  Holden  in  his 
obituary  notice  of  Mr.  Shuter  QSt.  Barthol.  Hasp.  B/p.,  vol.  xix.  p.  38),  it  is  stated 
that  "the  stump  was  sufficient  to  enable  the  patient  to  wear  an  artificial  limb  for  a 
time,  but  he  was  obliged  to  leave  it  off  on  account  of  its  weight."  I  have  now  per- 
formed this  amputation  seven  times.  Six  recovered,  and.  in  one  of  my  three  cases  in 
.adults,  a  delicate  girl  of  22  has  been  able  to  wear  a  very  light  limb,  made  by 
Messrs.  S.  Maw,  Son  and  Sons,  for  three  hours  at  a  time.  In  such  cases  as  these, 
where  the  patient  is  much  reduced  by  long-standing  hip  disease,  and  the  periosteum 
is  still  adherent  to  the  wasted  femur,  it  is  not,  in  my  opinion,  advisable  to  spend  time 
in  stripping  it  off.  While  the  shock  of  the  hip-joint  amputation  is  much  lessened  by 
this  method,  it  cannot,  of  course,  be  entirely  removed. 


58o  OPERATIONS   OX   THE  LOWER  EXTREMITY. 

fering-  with  the  operator,  by  the  following  method :  While  the  patient 
is  passing  under  the  anaBsthetic,  the  limb  is  emptied  of  blood  by  elevation 
and  application  of  Esmarch's  bandages  as  far  xip  as  the  tissues  are 
healthy ;  the  patient  is  then  rolled  over  on  to  his  sound  side,  and  a. 
piece  of  rubber  bandage  about  two  yards  long,  and  stout  enough 
to  require  decided  exertion  to  stretch  it  out  fully,  is  doubled  and 
passed  between  the  thigh  and  trunk,  its  centre  lying  between  the 
anus  and  tuber  ischii.  A  white  roller  bandage  of  appropriate  size  is- 
then  laid  over  the  termination  of  the  external  iliac  artery.  The  ends  of 
the  rubber  bandage  are  now  to  be  firmly  and  steadily  drawn  in  a 
direction  upwards  and  outwards,  one  in  front  of  the  groin  and  one  over 
the  buttock,  to  a  point  above  the  centre  of  the  iliac  crest,  siifiicient 
tightness  being  employed  to  stop  all  pulsation  in  the  femorals  or  tibials. 
The  front  part  of  the  band  passing  over  the  white  bandage  occludes  the 
external  iliac  and  runs  parallel  to  and  above  Poupart"s  ligament.  The 
posterior  part  runs  across  the  great  sacro-sciatic  notch  and  controls  the- 
branches  of  the  internal  iliac.  If  the  surgeon  is  short-handed,  instead 
of  the  cords  being  held  by  an  assistant,  they  may,  by  means  of  tapes 
strongl}^  stitched  to  them,  be  thus  secured :  having  been  drawn  with 
full  tightness  up  to  the  centre  of  the  iliac  crest,  they  may  be  crossed 
over  to  the  opposite  side  and  tied  firmly  (over  lint)  midway  between 
the  crest  and  the  top  of  the  great  trochanter.  If  a  strong  and  trusty 
assistant  is  forthcoming,  it  will  be  better  to  leave  the  bandage  in  his 
hands,  but  in  the  case  of  an  adult  whose  tissues  are  not  wasted,  and  on 
a  hot  day,  the  exertion  is  not  a  slight  one.* 

Whether  the  bandage  be  held  or  tied,  especial  care  must  be  taken 
that  it  does  not  slip  from  off"  the  external  iliac  nor  over  the  tuber  ischii. 
It  is  a  good  plan  to  pass  the  ends  of  the  india-rubber  band  over  a  slip 
of  wood,  so  as  to  diminish  the  prolonged  pressure  on  the  hands.  To 
prevent  the  bands  slipping  down  in  the  way  of  the  surgeon,  two  loops 
of  tape  or  bandage  may  be  thus  employed :  each,  about  two  feet  in 
length,  is  placed  longitudinally,  before  the  elastic  band  is  applied,  the 
one  over  the  groin,  the  other  well  behind  the  great  trochanter,  the 
centre  of  each  being  where  the  elastic  band  will  go.  When  the  band 
has  been  applied,  these  form  loops  by  means  of  which  the  band  is  kept 
well  out  of  the  operator's  way,  both  at  Poupart's  ligament  and  behind 
the  great  trochanter  (Jordan  Lloyd,  Lancet,   1883,  vol.  i.  p.  897). 

2.  PauVs  Method  (Lancet,  vol.  i.  1895,  p.  214).  This  is  a  modification 
of  the  above,  the  elastic  tourniquet  being  kept  in  place  by  means  of 
two  strips  of  calico  bandage.  One  passes  under  the  tourniquet  in  front 
and  behind,  and  over  the  point  of  the  opposite  shoulder,  the  other  passes 
under  the  tourniquet  in  the  same  way  and  round  the  opposite  hip. 
Mr.  Paul  has  tested  his  plan  in  seven  cases,  in  all  of  which  it  acted 
])erfectly  satisfactorily. 

3.  MaceweiiS  Method  of  Comjrresdoji  of  the  Ahdominal  Aorta  {Ann.  of 
Sur<j.,  1894,  vol.  i.  p.  i). — Prof.  Macewen  has  used  the  following  for 
many  years,   and  has  found   it    simple,   always    ready,    easily  applied 

*  As  will  be  seen  from  the  description  of  the  operation  below,  this  exertion  is  only- 
required  during  shelling  out  of  the  femur,  a  step  often  simplified  by  a  previous  ex- 
cision. During  the  circular  amputation  in  the  lower  third  of  the  thigh,  and  the 
securing  the  large  vessels  here,  there  is  abundant  room  to  control  these  by  an  Esmarch's 
bandage  applied  in  the  usual  way. 


i 


AMPUTATION  AT  THE  HIP-JOINT. 


581 


and  efficient.  No  injury  has  followed  to  the  small  intestines.  If 
the  patient  vomits  or  conghs  violentlj',  the  pressure  must  be  tem- 
porarily increased.  As  the  patient  lies  on  his  back  on  the  table,  the 
assistant,  facing  the  patient's  feet,  stands  on  a  stool  at  the  left  side 
of  the  table  in  a  line  with  the  umbilicus.  He  then  places  his  closed 
right  hand  upon  the  abdomen,  a  little  to  the  left  of  the  middle  line, 
the  knuckles  of  the  index  finger  first  touching  the  upper  border  of 
the  umbilicus  so  that  the  whole  shut  hand  will  embrace  about  three 
inches  of  the  aorta  above  its  bifurcation.  The  assistant  then  standing 
upon  his  left  foot,  his  right  foot  crossing  his  left,  leans  upon  his  right 
hand,  and  thereb}"  exercises  the  necessary  amount  of  pressure.  With 
the  index  finger  resting  upon  the  common  femoral  at  the  brim  of  the 
pelvis,  the  assistant  can  easily  estimate  the  weight  necessary  for  the 
purpose.  In  this  way  an  efficient  assistant  can  control  the  circulation 
for  half  an  hour  without  fatigue. 

4.    Wijetlis  Bloodless  Method  of  Amindation  at  the  Hip-Joint. — I  have 
mentioned  this  in  the  account  of  amputation  at  the  shoulder-joint  at 

Fig.  224. 


V 


Wyeth's  bloodless  method  of  amputation  at  the  hip-joint. 

p.  140,  Vol.  I.  It  has  been  largely  used  by  American  surgeons,  and  has 
given  excellent  results.  It  shares,  with  the  methods  of  Davy  and 
Tylden  Bro\^^le's  special  clamp  {Ann.  of  Sunj..  Feb.  1856,  p.  153),  the 
objection  of  needing  a  special  apparatus  which  will  not  be  always  at 
hand.  Further,  the  pins  must  be  passed  with  exactness,  and  unless  of 
sufficient  strength  will  certainly  bend  under  the  strain  of  the  cord 
above.  Its  use  is  thus  described  (Ann.  of  Surg.,  1897,  vol.  i.  p.  132): 
"  The  limb  to  be  amputated  should  be  emptied  of  blood  by  eleva- 
tion of  the  foot,  and  b}-  the  application  of  the  Esmarch  bandage, 
commencing  at  the  toes.  Under  certain  conditions,  the  bandage  can 
be  only  partially  applied.  When  the  tumour  exists,  or  when  septic 
infiltration  is  present,  pressure  should  be  exercised  only  to  within  five 
inches  of  the  diseased  portion,  for  fear  of  driving  the   septic  material 


582  OPEEATIONS  ON  THE  LOWER  EXTREMITY. 

into  the  vessels.  After  injui'ies  with  great  destruction,  crushing  or 
pulpefaction,  one  must  generally  trust  to  elevation,  as  the  Esmarch 
bandage  cannot  alwaj^s  be  applied.  While  the  member  is  elevated,  and 
before  the  Esmarch  bandage  is  removed,  the  rubber  tubing  constrictor 
is  applied.  The  object  of  this  constriction  is  the  occlusion  of  every 
vessel  above  the  level  of  the  hip-joint,  permitting  the  disarticulation  to 
be  completed,  and  the  vessels  secured  without  hsemorrhage  and  before 
the  tourniquet  is  removed.  To  prevent  any  possibility  of  the  tourniquet 
slipping,  I  employ  two  large  steel  needles  or  skewers,  three-sixteenths 
of  an  inch  in  diameter  and  ten  inches  long,  one  of  which  is  introduced 
one-fourth  of  an  inch  below  the  anterior  superior  spine  of  the  ilium  and 
slightly  to  the  inner  side  of  this  pi-ominence,  and  is  made  to  traverse 
superficially  for  about  three  inches  the  muscles  and  fascia  on  the  outer 
side  of  the  hip,  emerging  on  a  level  with  the  point  of  entrance  (Fig.  224.) 
The  point  of  the  second  needle  is  thrust  through  the  skin  and  tendon  of 
origin  of  the  adductor  longus  muscle  half  an  inch  below  the  crotch,  the 
point  emerging  an  inch  beloAv  the  tuber  ischii.  The  points  should 
be  shielded  at  once  with  cork  to  prevent  injury  to  the  hands 
of  the  operator.  No  vessels  are  endangered  by  these  skewers.  A 
mat  or  compress  of  sterile  gauze,  about  two  inches  thick  and  four 
inches  square,  is  laid  over  the  femoral  artery  and  vein  as  they  cross  the 
brim  of  the  pelvis  ;  over  this  a  piece  of  strong  white  rubber  tubing,  half 
an  inch  in  diameter  when  unstretched,  and  long  enough  when  in  position 
to  go  five  or  six  times  around  the  thigh,  is  now  wound  very  tightly 
around  and  above  the  fixation-needles  and  tied.  Except  the  small 
quantit}^  of  blood  between  the  limit  of  the  Esmarch  bandage  and  the 
constricting  tube,  the  extremity  is  bloodless  and  will  remain  so." 

The  Esmarch's  bandage  is  now  removed  and  a  circular  incision  is 
made  six  inches  below  the  tourniquet  joined  by  a  longitudinal  incision 
commencing  at  the  tourniquet  and  passing  over  the  trochanter  major. 
A  cuff  including  the  subcutaneous  tissue  down  to  the  deep  fascia  is 
dissected  off  to  the  level  of  the  trochanter  minor.  About  this  level  the 
remaining  soft  parts  are  divided  down  to  the  bone  with  a  circular  cut 
and  are  rapidly  dissected  from  the  femur.  The  vessels  should  now  be 
searched  for  and  both  arteries  and  veins  tied  with  o-ood-sized  catgut. 
The  muscular  attachments  are  separated  so  that  the  capsular  ligament 
may  be  exposed  and  divided.  The  limb  being  used  as  a  lever,  the  thigh 
is  forcibly  elevated,  abducted,  and  adducted,  letting  in  air  and  rupturing 
the  ligamentum  teres.  The  tourniquet  may  now  be  carefully  loosened 
and  all  bleeding  points  at  once  seized.  In  cases  of  great  exhaustion 
Dr.  W3^eth  would  do  the  operation  in  two  stages,  securing  the  vessels, 
dividing  the  femur  below  the  lesser  trochanter,  closing  the  wound  and 
turning  out  the  head  of  the  femur  about  two  weeks  later.  While  the 
633  cases  of  amputation  at  the  hip-joint  collected  by  Ashurst  showed  a 
mortality  of  64* I  per  cent.,  of  69  cases  performed  in  this  manner  only 
1 1  died — a  mortality  of  15  "9. 

5.  Davy's  Lever  (Fig.  225). — This  ingenious  instrument,  introduced 
by  Mr.  l)avy,  of  the  Westminster  Hospital,  consists  of  a  smoothly- 
tiirned  rod  of  ebony-wood  or  metal,  from  eighteen  to  twenty-two  inches 
long,  with  the  rectal  end  enlarged,  bluntly  conical,  and  most  carefully 
polished  and  graduated,  and  the  other  forming  the  handle. 

Oil  having  been  thrown  into  the  bowel,  the  rectal  end  is  introduced, 


AMPUTATION  AT  THE  HIP-JOINT. 


583 


Fig.  225. 


directed  towards  the  vessel  to  be  compressed,  and  felt  for  over  the 
situation  of  the  artery  through  the  abdominal  wall.  Thus,  if  the  right 
external  or  common  iliac  is  to  be  compressed,  the  handle  is  lowered  and 
carried  over  close  to  the  adductors  on 
the  left  side,  so  that  its  end  drops  over 
the  artery  on  the  pelvic  brim  (Fig.  225). 
Mr.  Davy  (Brit.  Med.  Journ.,  1879, 
vol.  ii.  p.  685)  claims  for  his  instru- 
ment the  following  advantcu/es  :  (a) 
More  perfect  control  of  both  ex- 
ternal and  internal  iliacs.  (/>)  It  in- 
flicts a  minimum  amount  of  dis- 
turbance on  the  respiratory  move- 
ments and  the  circulatory  system, 
(c)  It  is  generally  and  easily  ap- 
plicable. A  strictured  rectum  is  the 
sole  obstacle.  fSo  also  would  be  a  1 
short  and  tight  mesorectum.]  (d) 
The  pressure  applied  is  easily  main- 
tained, while  the  assistant  in  charge 
of  the  lever  is  out  of  the  way 
of  the  operator,  (e)  Its  application  is 
quite  safe  in  skilled  hands,  no  injury  having 
little  pain  having  been  suffered.  (/)  It  is 
has    been    successful.       Mr.    Davy,    in    his 


(After  Davy.) 

ever  resulted,  and  but 
cheap  and  simple,  (g)  It 
paper    above    quoted,   had 


records  of  ten  cases  in  which  the  lever  had  been  emploj-ed  ;  the  total 
amount  of  blood  lost  during  the  ten  operations  had  been  under  18  oz., 
and  there  had  been  80  per  cent,  of  recoveries.  Disadfantages. — Simple 
and  ingenious  as  the  above  method  is,  it  is  beyond  doubt  that  it  has 
caused  a  fatal  result  from  injury  to  the  peritonaeal  coat  of  the  rectum. 
It  is  now  likely  to  be  replaced  by  the  Jordan-Lloyd  method.  On 
account  of  the  above  risk  I  prefer  to  meet  the  haemorrhage  either  by 
the  above-mentioned  method,  or,  where  this  is  impossible,  by  securing 
the  vessels  before  they  are  cut  (p.   584). 

6.  Gompressiiiij  the  Gommon  Femoral  or  the  Termination  of  the  External 
Iliac  by  the  fingers  or  hands,  aided,  if  need  be,  by  a  weight.  This  is 
only  possible  in  the  case  of  a  child,  and  the  assistant  thus  employed 
is  liable  to  be  in  the  way  of  the  operator. 

7.  Lister's  Tourniquet. — This  means  of  compressing  the  termination  of 
the  abdominal  aorta  is  not  a  light  matter,  apart  from  the  xevj  grave 
operation  into  which  it  enters.  This  is  owing  to  the  difficulty  of  making 
sure  of  avoiding  such  important  sti'uctures  as  the  duodenum,  pancreas, 
solar  plexus,  and  small  intestines,  and  to  its  interference  with  respira- 
tion and  circulation.  The  bowels  must  be  thoroughly  emptied  before- 
hand, and  got  out  of  the  way  by  gently  rolling  the  patient  on  to  his 
right  side  before  the  pad  is  applied.  In  the  Amer.  Text-hook  of  S'urg., 
p.  1 193,  two  useful  hints  are  given,  one  to  apply  a  soft  sponge  between 
the  pad  and  the  skin,  and  the  other  to  lose  not  a  moment  in  putting 
catch-forceps  on  the  chief  bleeding  points  after  the  main  vessels  have 
been  tied,  so  that  the  tourniquet  may  be  promptly  loosened. 

8.  Compression  of  the  Common  Iliac  through  an  Abdominal  Incision. 
(Dr.  0.  McBurney,  Ann.  of  Surg.,  Aug.  1894,  P-  1 81). 


584 


OPERATIONS  ON  THE  LOWER  EXTREMITY. 


Fig.  226. 


9.  Commcmding  the  Main  Artery  during  the  operation  either  by 
seizing-  a  flap  (Figs.  228  and  229),  or  b}-  securing  the  vessels  before 
t\\ej  are  divided. 

The  above  statistics  of  Wyeth's  method  are  very  good,  but  I  believe 
that  the  Jordan-Lloyd  method,  if  carefully  carried  out,  will  give  as  good 
results  without  the  need  of  relying  on  any  special  instruments  which 
may  not  be  at  hand  just  when  required.  In  support  of  this  I  may  say 
that  I  have  had  seven  cases  and  only  lost  one.  I  am  very  strongly  of 
opinion  that  two  methods  of  arresting  haemorrhage  here  will  be  found 

sufl&cient  for  all  cases,  i .  Furneaux 
Jordan's  amputation,  aided  by  the 
Jordan-Lloyd's  method  of  compres- 
sion (p.  579).  This  will  suffice  for 
all  cases  of  hip  disease  which  form 
the  great  majority  of  cases  calling 
for  amputation  here.  2.  In  the 
much  smaller  class  of  accident  or 
growths  by  using  Prof.  Macewen's 
method  (p.  580)  and  by  securing 
the  vessels  before  they  are  cut, 
the  flaps  being  made  according  to 
the  need  of  the  case.  In  every  case 
of  amputation  at  the  hip-joint  shock 
should  be  met  by  making  a  saline  in- 
fusion while  the  amputation  is  being- 
performed. 

Furneaux      Jordan's      Operation 

fFig.  226). — Every  provision  must  be 

taken    against    shock.       The     limbs 

should  be   bandaged  in  cotton-wool, 

the  bod}^  well  wrapped  up  on  a  hot- 

Furneaux  Jordau'.s  amputation.    Above  water  table,  the  head  kept  low,  ether 

is  shown  the  means  of  controlling  hsemor-  given,     stimulant    rectal     injections 

rhage  described  at  p.  579.     Lower  down  j^gp^  at   hand,  and  subcutaneous  in- 

are  seen  the  sinuses  of  an  imhealed  excision,    •    „j.*    „„     „f    l^„„„j„     „,  j      ^-t-^,^^!,,,;,-.,^ 

,,,        i.1    1   f  ,   ,,-        ..  rxi    r  lections    ot    brandy    and    strychnine 

and  tlie  method  of  shelhng  out  of  the  femur,   '■  n  ,-  "^    . 

after  a  circular  amputation  has  been  per-    given  trom  time  to  time, 

formed,  and  the  large  vessels  secured.  Before    Commencing    the    circular 

amputation,  I  have  the  limb  elevated, 
an  Esmarch  bandage  applied  up  to  the  knee,  the  thigh  emptied  of 
venous  blood  bv  tirm  stroking,  and  a  second  Esmarch  bandage  then 
applied  firmly  just  below  the  trochanters,  and  the  lower  one  removed. 
The  india-rubber  band  is  also  (p.  579)  placed,  lightly,  ready  in  situ. 
The  circular  amputation  is  then  performed,  and  the  large  vessels 
secured.  The  upper  Esmarch  is  next  removed,  and  the  india-rubber 
band  firmly  tightened  A\'hile  the  femur  is  shelled  out  or,  perhaps, 
disarticulated. 

The  patient's  pelvis  is  brought  to  the  edge  of  the  table  and  the  bod}^ 
rolled  a  little  on  to  the  sound  side,  the  surgeon  standing  usually  to  the 
right  of  the  diseased  limb — i.e.,  inside  on  the  left  and  outside  on  the 
right  side — draws  up  the  soft  parts  forcibl}^  with  his  left  hand,  and 
makes  a  circular  incision  through  the  lower  third  of  the  thigh,  using 
his    knife  as  at  p.  624,  the  assistant  who  is    in  charge  of  the   limb 


A^^IPUTATIOX  AT  THE  HIP-JOINT.  585 

rotating-  it  so  as  to  make  the  tissues  meet  the  knife.  A  circular  cuff- 
like  flap  of  skin  and  fasciae  is  then  quickly  raised  for  about  two  inches 
and  a  half,*  an  assistant,  who  stands  opposite  the  surgeon,  giving  much 
help  here,  by  seizing  and  everting  the  cut  edge  of  the  flap  as  the 
surgeon  raises  it.  The  flap  being  drawn  upwards  out  of  the  way,  the 
soft  parts  are  severed  by  one  or  two  vigorous  circular  sweeps  down  to 
the  bone,  and  the  large  vessels  and  any  others  that  can  be  seen  are  next 
secured.  Pressure  f  is  now  made  with  sterilised  sponges  on  the  still 
oozing  wound,  and  the  patient  being  rolled  well  over  on  to  his 
sound  side,  the  surgeon  cuts  along  the  outer  side  of  the  thigh,  starting 
from  the  circular  wound  and  ending  about  midway  between  the  iliac 
crest  and  top  of  the  great  trochanter.  This  incision  goes  straight  down 
to  the  bone  and  runs  into  any  excision  wound,  or  sinuses  which  may 
exist  over  the  joint.  The  soft  parts  are  then  rapidly  stripped  off  the 
femur,  partly  with  the  knife,  partly  with  the  finger,  the  only  difficulty 
met  with  benig  along  the  linea  aspera.  If  an  excision  has  been  per- 
formed, the  operation  is  rapidly  completed,  bvit  if  the  head  and  neck 
remain  intact,  the  final  steps  will  be  rendered  more  difficult,  and  the 
joint  must  be  opened  from  the  outside  by  cutting  strongly  on  the  neck 
of  the  bone,  this  being  facilitated  by  the  assistant  moving  the  limb. 
in  accordance  with  the  surgeon's  directions,  as  different  parts  require 
to  be  put  on  the  stretch,  strong  outward  rotation  of  the  femur 
and  dragging  of  the  head  away  from  the  acetabulum  being  required 
at  the  last. 

Free  drainage  must  be  provided,  for  it  must  be  remembered  that  the 
wound  left  by  this  method  is  a  very  large  one,  though  it  has  the 
advantage  of  being  farther  removed  from  sources  of  sepsis.  Thus, 
especially  if  the  tissues  are  riddled  with  sinuses,  too  much  of  the  wound 
must  not  be  closed,  and,  if  shock  is  present,  the  surgeon  must  not  wait 
to  insert  many  sutures,  but.  trusting  to  firm  bandages  over  an  aseptic 
dressing,  get  his  patient  quickly  back  to  bed.  If  disease  of  the 
acetabulum  be  present  the  surgeon  will,  if  the  patient's  condition  admit 
of  it,  attend  to  this,  the  use  of  a  sharp  spoon  (Fig.  237)  and  the 
insertion  of  a  drainage-tube  throvigh  this  bone  being  specially  required 
if  pelvic  suppuration  be  present. 

In  some  cases  shock  is  marked  from  the  beginning  of  the  operation. 
This  was  most  markedly  the  case  in  one  of  the  patients  mentioned  in 
the  footnote,  p.  579,  a  very  delicate  young  lad}"  of  22.  It  was 
■only  by  not  waiting  to  do  more  than  secure  the  femoral,  making- 
firm  sponge-pressure  on  the  flaps,  tilting  up  the  end  of  the  table 
so  as  to  keep  the  head  low,  inserting  no  sutures,  but  trusting  only 
to  firm  bandaging  over  dry  gauze  dressings,  that  a  fatal  result  was 
averted. 

Amputation  by  Different  Flap  Methods. — The  following  will  be 
^•iven  here,  it  being  understood  that  in  no  case  can  any  of  them  be 
recommended  if  Furneaux  Jordan's  method  is  available  : 


*  The  surgeon  need  not  trouble  to  raise  a  larger  circular  flap.     As  the  femur  is 

removed,   the   muscles  lose  iheir  fixed  point  to  contract  from,  and  are  thus  easily 
■covered. 

t  Valuable  time  should   not  be  wasted   in   trying  to  secure  every  bleeding-point 
cither  now  or  later. 


586 


OPERATIONS  ON  THE  LOWER  EXTREMITY, 


II.  Antero-posterior  Flaps  (Figs.  227-230).  Methods  of  Guthrie 
and  Liston. — The  patient  having  been  prepared  against  shock  (p.  584), 
and  the  main  vessels  secured  by  one  of  the  methods  already  given,  the 
limb  being  brought  over  the  table  and  supported  in  the  semi-flexed 
position  by  an  assistant,  while  the  opposite  limb  is  secured  over  the 
table  by  a  bandage,  the  surgeon,  standing  outside  the  left  and  inside  the 

Fig.  227. 


(Fergusson.)* 

right  limb,  raising  the  tissues  in  front  of  Scarpa's  triangle  with  his  left 
hand,  enters  his  knife  {e.g.,  on  the  left  side)  midwaj^  between  the 
anterior  superior  spine  and  the  top  of  the  great  trochanter,  and  sends 


Fig.  228. 


Fig.  229. 


it  across  the  limb  so  that  it  emerges  close  to  the  tuberosity  of  the 
ischium.  In  traversing  the  limb  the  knife  should  pass  as  close  to  the 
capsule  as  possible,  so  as  (i  j  to  get  behind  the  large  vessels,  and  (2)  to 


*  The  knife  represented  here  is  needlessly  long. 


AMPUTATION  AT  THE  HIP-JOINT. 


587 


Fig.  230. 


facilitate  the  opening  of  the  capsnle  later  on.  As  the  knife  emerges 
the  surgeon  will,  of  course,  be  careful  of  the  scrotum  and  the  opposite 
thigh,  and  at  this  moment  the  point  should  be  well  depressed,  so  as  to 
include  all  the  tissues  possible  in  the  anterior  flap.  With  a  rapid 
sawing  movement  a  broad  flap  is  cut,  five  inches  long,  an  assistant 
thrusting  his  fingers  into  the  wound  as  it  is  made,  and  following  the 
back  of  the  knife,  to  secure  the  large  vessels  (Figs.  228.  229J.  As  he 
then  draws  up  the  anterior  flap  the  capsule  is  exposed,  covered  A\'ith 
more  or  less  of  soft  parts,  according  to  the 
skill  with  which  the  knife  has  been  first 
inserted ;  the  assistant  in  charge  of  the 
limb  at  this  moment  extending,  depressing, 
and  rotating  out  the  femur,  so  as  to  put  the 
capsule  on  the  stretch,  the  surgeon  forcibly 
draws  the  knife  across  the  capsule,  opens  it 
freely,  and  divides  the  ligamentum  teres 
(Fig*  230). 

The  limb  being  now  slightly  flexed,  ad- 
ducted,  and  pulled  away  from  the  bod}',  the 
surgeon  severs  the  parts  attached  to  the 
great  trochanter  and  the  outer  aspect  of  the 
limb,  and,  passing  his  knife  behind  the 
bone,  cuts  a  posterior  flap  about  four  inches 
long.  The  assistant  in  charge  of  the  limit 
will  facilitate  this  step,  and  further  the 
dislocation  of  the  femur,  if  he  bring  the 
thigh  upwards  and  forwards  with  one  hand 

placed  at  the  back.  A  large  gauze  pad  wrung  out  of  one-in-twenty 
carbolic  acid  is  at  once  pi-essed  against  the  posterior  flap  while  the 
femoral  vessels*  are  secured,  or,  if  these  are  well  in  hand,  those  in  the 
hinder  flap  are  taken  first.  The  glutasal  will  be  found  in  the  giutaeal 
muscles,  the  sciatic  with  the  nerve  nearer  the  posterior  margin  of  the 
flap,  and  the  circumflex  and  obturator  closer  to  the  acetabulum. 

If  the  patient's  condition  admits  of  it,  any  sinuses  are  now  laid  open 
or  scraped  out.  the  acetabulum  examined,  and.  if  perforated,  drained. 
If  the  amputation  has  been  for  growth,  any  outlying  masses  are  looked 
for  and  removed.  Anj'  nerves  or  muscles  which  need  it  are  now 
trimmed  short,  a  large  drainage-tube  inserted,  and  the  flaps  carefully 
united. t 

Advantci'jes  of  this  method  :  Chief  of  these  is  its  rapidity. — Disad- 
vantages :  I.  The  hgemorrhage  which  takes  place  from  the  vessels  from 
the  posterior  flap  may  be  considerable.  2.  The  large  amount  of  sero- 
sanguineous  oozing  which  takes  place  from  so  many  large  muscles  cut 
obliquely.  3.  The  fact  that,  in  an  adult,  it  requires  a  special,  long 
knife,    not    alwavs   found   in   an    ordinarv    collection    of    instruments. 


*  Of  these  the  femoral  lies  superficially,  the  profunda  more  deeply,  iu  the  anterior 
flap  ;  they  arc  shown  much  too  close  to  each  other  in  Fig.  229. 

t  If  grave  shock  is  present,  the  head  should  be  lowered  and  sutures  put  in,  any 
oozing  being  stopped  by  firm  spica-bandaging,  and  Spencer  WcUs's  forceps  left  in  situ. 
The  lower  end  of  the  bed  should  be  kept  raised,  and  brandy  given  subcutaneously 
and  per  rectum.     Transfusion  should  also  be  employed  early  (p.  5S4). 


588 


OPERATIONS  OX  THE  LOWER  EXTREMITY. 


Bifficulties  :  I.  Not  passing  the  knife  cleepl)'  enough,  and  thns  not 
exposing  the  capsule.  2.  Passing  the  knife  too  deeply,  and  hitching 
its  point  on  the  bone.  3.  Getting  the  knife  stopped  in  passing  it 
behind  the  head  of  the  femur.     4.   Fracture  of  the  femur. 

Guthrie's  Method  by  Antero-posterior  Flaps. — ^Antero-posterior 
flaps  are  again  made  use  of,  but  here  the}'  are  made  from  without 
inwards,  and  thus  can  easily*  be  rendered  less  biilky.  A  small  knife — 
i.e.,  one  four  inches  long — sulhces. 

%•  The  preparatory  steps  being  taken  as  before,  the  surgeon,  standing 
on  the  right  side  of  either  limb,  marks  out  his  anterior  flap,  about  five 

inches  long,  by  an  incision ,  start- 
FiG.  231.  ing  (on  the  left  limb)  from  just 

above  the  great  trochanter,  pass- 
ing across  the  thigh  with  a  broadly 
curved  convexity,  and  ending  just 
below  the  tuber  ischii.  A  pos- 
terior flap  is  then  mai'ked  out  by 
carrjang  the  knife  in  a  similar 
manner  across  the  back  of  the 
limb  between  the  same  points, 
the  limb  being  raised  and  the 
su.rgeon  stooping  somewhat.  This 
flap  should  be  about  two-thirds 
the  length  of  the  first.  Both  con- 
sist of  skin  and  fasciae.  The  flaps 
being  held  out  of  the  way,  the 
muscles,  first  on  the  front  and 
then  on  the  back,  are  next  cut 
obliquely  from  below  upwards,  the 
femoral  vessels,  both  superficial 
and  deep,  being  secured  as  soon 
as  the}^  are  exposed,  and  before 
the}"  ai'e  cut,  either  by  underrun- 
ning  them  with  an  aneurysm- 
needle  loaded  with  silk,  or  by 
dividing  them  between  two  pairs 
of  forceps.  The  capsule  being 
exposed,  disarticulation  is  i)er- 
formed  as  before. 

III.  Lateral  Flaps. — The 
methods  of  Larry  and  LisfranC 
need  not  be  more  than  alluded  to 
here.  In  both,  the  flaps  were  cut 
by  transfixion,  and  were  about 
four  inches  long.  Larry  tied  the  common  femoral  as  a  preliminary  step. 
Flaps  made  by  either  method  are  so  bulky  as  not  to  be  recommended. 

If  the  surgeon  wishes  to  use  lateral  flaps,  as  in  a  case  involved  by 
growth  in  front,  he  may  make  them,  thus,  from  without  inwards : 
Standing  on  the  right  side  of  either  limb,  he,  e.r/.,  in  the  case  of  the 
right  limb,  marks  out  an  inner  flap  by  means  of  an  incision  starting 
from  below  the  tuber  ischii,  carried  downwards  along  the  inner  as]3ect 
of  the  thigh  for  about  four  inches  and  then  curving  upwards  to  the 


Amputatiou  at  the  liip-joint  by  modified 
lateral  flaps  (anterior  racquet-shaped  incision). 
1,  The  ^sartorius.  2,  The  ilio-psoas.  3,  The 
rectus.  4,  The  tensor  vaginae  fenioris.  Tliese 
have  been  cut  and  retractors  have  exposed 
(5  and  6)  the  internal  and  external  vasti.  A 
double  ligature  has  been  placed  uijon  the 
common  femoral  vessels.     (Farabeuf.) 


AMPUTATIOX   AT  THE   Hli'-JOLXT. 


589 


ce7itre  of  the  groin  and  ending,  a  little  below  PoTipart's  ligament,  to  the 
outer  side  of  the  femoral  vessels  :  next,  without  taking  off  his  knife, 
he  marks  out  an  outer  flap  by  cutting  between  the  same  points,  but  in 
the  reversed  direction.  This  incision,  as  it  passes  downwards,  outwards, 
and  backwards,  should  leave  the  front  of  the  limb  about  a  hand's-breadth 
below  the  great  trochanter.  The  flaps  having  been  dissected  up,  the  soft 
parts  are  cut  through  from  without  inwards,  the  femoral  vessels  being 
secured  before  they  are  cut.  and  disarticulation  performed  last. 

1\.  Antero-internal  and  Postero-external  Flaps  (Figs.  231.   232, 
233). — This  is  a  modification  of  the  last  method,  and  may  be  useful  in 

cases  of  growth  extending  high 
Fig.  232.  up,   where   it    is   impossible    to 

perform  a  Furneaux  Jordan's 
amputation.  Some  such  flaps 
as  the  above  may  be  the  only 
ones  obtainable.  They  may  be 
made  as  follows :  The  precau- 
tions as  to  shock  given  at  p.  584 
having  been  taken,  the  patient's 


The  same  operation  as  in  the  last  figure,  in  a 
more  advanced  stage.  The  capsule  has  been 
opened  and  its  outer  lip  drawn  aside  by  a 
retractor.  The  other  retractor  draws  inwards 
and  protects  the  vessels,  i,  Sartorius.  2,  Psoas. 
3,  Rectus.  4,  Tensor  vagiuse  femoris.  5,  At- 
tachment of  gluteus  miuimus.     (Farabeuf.) 

pehis  having  been  brought  well  down  to  the  edge  of  the  table,  and  the 
opposite  limb  being  held  aside  but  not  tied,  the  surgeon,  standing  to 
the  right  of  either  limb,  reaches  somewhat  over  and  marks  out  (in  the 
case  of  the  right  limb)  an  antero-internal  flap,  but  cutting  from  a  point 
close  to  the  tuber  ischii  to  one  a  little  below  and  internal  to  the  anterior 
superior  iliac  spine.  The  skin  and  fascia  having  been  dissected  up, 
the  muscles  are  cut  through  till  the  femoral  vessels  are  reached  and 
secured.  Sterilised  gauze  is  now  packed  into  this  wound,  and,  the 
patient    having    been  rolled  a   little    over,   a    postero-external    flap    is 


590  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

marked  out  and  dissected  up  from  the  glutaeal  region,  passing  between 
the  above  points,  but  in  the  reverse  order.  The  glutseal  vessels  are 
next  cut  through,  the  chief  vessels  being  secured  by  Spencer  Wells's 
forceps ;  the  capsule  is  then  opened,  the  round  ligament  severed,  and 
the  limb  removed. 


EXCISION    OF    THE    HIP. 

Indications, — A.  Disease.     B.  Injury,  especially  gunshot. 

A.  Disease. — The  value  of  excision  here  has  been  much  disputed. 
The  chief  questions  are :  Does  it  save  life  ?  Does  it  shorten  treat- 
ment?    Is  the  limb  a  better  one? 

To  take  two  of  the  chief  writers  on  hip  disease  and  the  subject  of 
excision,  Mr.  Howard  Marsh,*  with  his  experience  gained  from  Great 
Ormond  Street  and  the  Alexandra  Hospital  for  Hip  Disease  in  Child- 
hood, and  Mr.  G.  A.  Wright,!  of  Manchester  and  the  Pendleburj^ 
Hospital  for  Sick  Children.  Mr.  Marsh  is  strongly  against  excision, 
for  these  reasons :  He  considers  the  results  obtained  by  continued  rest 
to  be  such  as  to  render  excision  totally  uncalled  for.  Thus,  continued 
rest  gives  a  mortality  of  only  5  per  cent.,  70  per  cent,  of  the  cases  thus 
treated  recovering  with  only  slight  lameness  and  loss  of  movement. 
Even  when  suppuration  has  occurred,  the  mortality  is  only  6  or  8  per 
cent.  Again,  at  p.  309,  Mr.  Marsh  writes  :  "  The  estimate  that  I  have 
been  led  to  form  is,  (a)  that,  in  the  early  stage  of  the  disease,  although 
matter  is  developed,  the  operation  is  as  unjustifiable  as  it  is  to  remove  a 
testis,  an  eye,  or  a  tooth  for  incipient  but  still  curable  disease ;  (h)  that 
the  operation  is  generally  uncalled  for,  even  when  sinuses  have  formed ; 
(c)  that  if  hip  disease  has  been  allowed  to  reach  the  stage  in  which  the 
bones  have  become  extensively'  carious,  in  which  matter  has  burrowed 
widely,  and  in  which  the  general  health  has  become  seriously  affected, 
excision  will  be  of  verj'  doubtful  benefit.  The  operation  will  be  fatal  in 
at  least  10  per  cent,  of  the  cases,  while  in  another  20  or  25  per  cent,  it 
will  be  followed  by  no  improvement  in  the  patient's  condition." 

On  the  other  hand,  ni}*  old  friend,  G.  A.  Wright,  speaking  from  the 
very  large  experience  of  over  a  hundred  cases  of  excision,  of  which  onlj'' 
three,  at  most,  died  of  the  direct  results  of  the  operation,  strongly  urges 
that  the  hip  should  be  excised  "  as  soon  as  there  is  any  evidence  of 
external  abscess,  .  .  .  and  still  better  results  would,  I  believe,  be 
obtained  by  operating  before  the  pus  has  escaped  from  the  articulation. 
Tlie  operation  is  discredited  because  it  is  put  off  until  disease  is  so  far 
advanced  that  no  treatment  can  have  more  than  a  fraction  of  good 
results ;  while  timely  excision  cuts  short  the  disease,  saves  pain,  lessens 
the  time  of  treatment,  and  gives  a  better  limb."  And  again,  at  p.  97 
of  his  book,  Mr.  Wright  says :  '•  While  fully  aware  that  abscesses 
disappear  and  tuberculous  lesions  cicatrise  under  favourable  circum- 
stances, I  think  that,  in  the  case  of  the  hip,  delay  is  unwise  amongst 
the  hospital  class,  with  whom  it  is  as  yet  impossible  to  deal  on  the  same 
lines  as  with  the  well-to-do.  In  almost  every  instance  I  have  found 
much  more  extensive  disease  than  might  be  expected  from  the  external 

*  Diseases  of  the  Joints,  p.  317.  f  Hip  Disease  in,  Childhood,  p.  93. 


EXCISION   OF  THE  HIP.  59 1 

evidence,  unless  the  pathology  of  the  affection  is  borne  in  mind :  and  I 
believe  that,  once  this  chronic  osteo-myelitis  is  established,  nothing 
short  of  excision  can,  in  hosjntal  cases,  prevent  the  ultimate  progress 
of  the  disease  to  abscess,  and  too  often  to  gradual  exhaustion  of  the 
patient  by  pain  and  discharge.  Xature,  of  course,  in  many  cases  will, 
unaided,  get  rid  of  the  dead  bone  by  slow  and  tedious  processes,  but 
the  number  of  children  who  can  survive  the  process  of  elimination  is 
very  small,  while  the  mortality  after  early  excision  is  not  great,  and  the 
failures  are  mainly  in  those  instances  where  the  operation  has  been  put 
off  till  too  late.  Where  actual  necrosis,  or  caries  of  the  head  of  the 
femur,  Avith  destruction  of  bone  and  cartilage,  and  often  sequestra  of 
varying  size  in  the  acetabulum,  or  at  least  caries  of  it,  are  kno^vn  to 
exist.  I  think  few  advocates  of  non-operative  treatment  will  be  found." 
AMtli  reference  to  so  wide  a  divergence  of  opinion  between  two  authori- 
ties on  the  subject,  it  may  be  pointed  out  that  Mr.  H.  Marsh  worked 
under  conditions  more  favourable  than  those  which  fall  to  the  lot  of 
most  hospital  sui'geons.  Thus,  at  the  Alexandra  Hospital,  cases  are 
kept  under  treatment  as  long  as  rest  and  extension  are  required ;  if  an 
operation  is  called  for,  the  case  is  transferred  elseAvhere.  TSTiile  eveiy- 
one  must  admire  Mr.  Marsh's  success,  it  is  clear  that  the  conditions 
under  which  it  has  been  gained  must,  as  yet.  stand  almost  alone. 

Reference  must  here  be  made  to  a  most  important  contribution  to 
the  study  of  the  treatment  of  hip  disease  by  Drs.  Gibney,  Waterman, 
and  Reynolds,  of  New  York  (Ann.  of  Surg.,  vol.  ii.  1897,  p.  435). 
An  analysis  is  given  of  150  cases  treated  at  the  New  York  Hospital 
for  Ruptured  and  Crippled.  Of  these  25  were  still  under  treatment, 
and  need  not  be  further  considered  ;  7  were  advised  readmission  for 
deformity,  11  died,  and  107  were  cured.  The  107  cured  cases  were 
finally  examined  at  an  interval  of  five  to  twenty  years  after  leaving  the 
hospital.  The  excellence  of  the  final  result  in  the  cured  cases,  all  of 
which  recovered  with  sound  and  useful  limbs,  will  be  gathered  from  the 
following  facts.  As  regards  motion,  this  was  perfect  in  15,  good  in  22. 
limited  in  41,  and  absent  in  only  9  cases.  Shortening  averaged  an  inch 
and  three-fifths  in  all  the  cases,  but  was  absent  in  21  cases  :  under  one 
inch  in  7 1 ,  and  over  one  inch  in  t,6.  The  record  as  regards  flexion  is 
also  extremely  satisfactoiy,  as  47  cases  had  none  at  all,  and  in  yy  it 
was  under  10'^  ;  in  the  remaining  30  cases  it  was  under  30'^. 
The  treatment  employed  consisted  essentially  in  rest  and  extension  : 
abscesses  being  either  aspirated,  or  opened  and  curetted.  Osteotomy 
of  the  femui-  was  performed  19  times  to  correct  deformity,  but  excision 
was  done  in  4  cases  only. 

Briefly  stated,  of  114  cases  examined  five  years  and  upwards  after 
leaving  the  hospital.  107  ••  were  cured  and  able  to  follow  an  occupation 
without  the  slightest  trouble.'"  and  the  remaining  7  cases  were  cured 
but  suffering  from  considerable  deformity.  As  excision  was  performed 
in  only  4  of  these  cases,  it  must  be  admitted  that  these  excellent 
results  constitute  very  strong  evidence  in  favour  of  the  conservative 
treatment  advocated  by  ^Mr,  Marsh. 

My  own  opinion  as  to  the  advisability  of  excision  in  the  ordinary 
hip  disease  of  hospital  cliildren  is,  that  it  should  be  resorted  to  (i) 
when  suppuration  is  present,  and  persists  in  spite  of  a  fair  trial  of 
rest,  and  antiseptic   incision,  this    latter  step  giving  an  opportunity, 


592  OPERATIONS  ON  THE  LOWER  EXTREMITY. 

though  a  limited  one,  of  investigating  the  amount  of  disease  present ; 

(2)  when  thei'e  is   much  thickening  about  the  great  trochanter;   and 

(3)  when  there  is  much  pain,  especially  at  night,  not  yielding  to  a  due 
trial  of  rest.  But  while  I  should  thus  advocate  the  performance  of  the 
operation  in  the  second  stage,  I  think  that  sufficient  importance  has  not 
been  attached  to  the  fact  that  disease  of  this  most  important  joint 
is,  unless  not  only  seen  but  treated  in  the  first  stage,  severe  and 
progressive,  and,  p^r  se,  likely  to  end  fatally ;  if  this  be  so,  excision 
must  not  be  too  much  reproached  with  failure.  The  depth  of  the  joint, 
the  needful  interference  with  soft  parts,  the  difficulty  of  keeping  the 
wound  aseptic  in  children,  the  kind  of  patient,  and  the  tubercular 
origin  of  the  disease,  must  always  be  remembered.  For  these  reasons 
I  cannot  quite  agree  with  G.  A.  Wright  {Bis.  of  Children,  p.  558), 
"that  excision,"  as  soon  as  suppuration  and  other  evidence  of  necrosis 
is  present,  "  should  be  looked  on  as  an  ordinary  operation  for  necrosis, 
and  the  operation  itself  is  not  necessarily  attended  by  a  higher 
mortality  than  sequestrotomy  elsewhere." 

The  following  are  the  conditions  given  by  the  Clinical  Society's 
Committee  on  excision  of  the  hip-joint  as  calling  for  excision,  viz.  : — 

i.  "  Necrosis,  and  separation  of  the  entire  head  of  the  femur,  and  its 
conversion  into  a  loose  sequestrum."  * 

ii.  "  The  presence  of  firm  sequestra  either  in  the  head  or  neck  of  the 
femur,  or  in  the  acetabulum."  This  cjuestion  is  a  most  important  one, 
for,  as  Mr.  Marsh  (p.  318)  wi'ites,  "  much  difference  of  opinion  exists  as 
to  the  frequency  with  which  hard  sequestra  of  any  material  size  are 
present  in  suppurative  hip  disease."'  He  himself  thinks  that,  when 
present,  sequestra  usually  consist  of  porous,  friable  bone.  Their 
structure  is  such  that,  should  excision  not  be  performed,  they  will 
crumble  away  and  disappear,  and  will  not  prevent  repair.f  A  distinctly 
different  opinion  is  held  by  Mr.  Wright  {JLoc.  supra  cit.,  p.  118):  "  Here 
opening  of  abscesses,  and,  still  less,  expectant  treatment,  can  hardly  be 
considered  a  satisfactory  mode  of  getting  rid  of  sequestra,  yet  in  no  less 
than  in  39  (out  of  1 00)  were  there  actual  loose  sequestra,  while  in  many 
others  there  were  patches  of  bone  which  was  practically  dead,  though 
not  loose.  The  possibility  of  removing  sequestra  w^ithout  a  formal 
excision  is  worth  trying  in  some  cases,  but  it  is  often  impossible  to 
discover  the  presence  of  the  sequestra  until  the  end  of  the  bone  has 
been  removed,  or  to  extract  them  if  found.  Moreover,  even  after  the 
removal  of  sequestra,  others  may  exist  and  not  be  found,  and  in  other 
instances  the  disease  progresses  in  the  surrounding  bone  and  necessi- 
tates subsequent  excision.     There  are  often,  too,  other  foci  of  disease  in 

*  Mr.  Marsh  (^loc  supra  cit.,  Fig.  50,  p.  383)  thinks  that  these  cases  are  not  rare. 
Mr.  Hilton  (^Rest  and  Pain,  Fig.  63,  p.  341)  shows  a  similar  specimen.  I  should  have 
thought  the  condition  a  very  uncommon  one. 

f  "  This  seems  to  be  proved  by  the  fact  that  in  numerous  cases  in  which  profuse 
suppuration  has  been  going  on,  so  that  there  can  be  no  reasonable  doubt  that 
extensive  bone  disease  has  been  present,  all  the  sinuses  will  close,  although  either  no 
bone  has  worked  out  or  been  extracted.  In  these  instances  we  must  conclude  either 
that  no  sequestra  were  present,  and  in  that  case  it  would  appear  that  sequestra  are 
not  so  common  as  some  believe,  or  that  they  often  crumble  away  and  are  discharged, 
so  that  operative  interference  is  by  no  means  essential  for  their  removal "  (Marsh,  loc. 
.vipra  cit.,  p.  319). 


EXCISlOX  OF  THE  PUP.  593 

the  medulla,  which  are  as  great  bars  to  recovery  as  the  sequestra 
themselves." 

iii.  "  Extensive  caries  of  the  femur,  or  the  pelvis,  leading  to 
prolonged  suppuration  and  the  formation  of  sinuses." 

iv.  "  Intra-pelvic  abscess  following  disease  of  the  acetabulum." 

With  reference  to  these  conclusions  I  should  doubt  nwself  whether 
excision  can  be  often  justifiable,  especially  in  the  latter.  Even  if  it 
gave  the  desired  drainage  the  patient's  condition  with  disease  of  the 
acetabulum  is  not  one  usually  to  give  the  required  repair  after  excision. 
•'  Extensive  caries  "  of  the  pelvis  certainly,  and  in  many  cases  of  the 
femur,  will  require  amputation,  especially  after  childhood. 

V.  ••  Extensive  and  old-standing  synovial  disease  and  ulceration  of 
the  articular  cartilages,  with  persistent  suppuration.""  This  condition  is 
rarel}'  seen  in  the  hip-joint,  where  the  disease,  as  usually  met  with, 
starts  not  in  the  synovial  membrane,  as  in  the  knee-joint,  but  as  a 
chronic  osteo-myelitis  in  the  neighbourhood  of  the  epiphyses,  especially 
the  upper  one. 

vi.  '■  Displacement  of  the  head  of  the  femur  on  the  dorsum  ilii.  with 
chronic  sinuses  and  deformit}*.'" 

This  condition  will  probably  be  more  rarely  met  with  nowadays,  as 
earlier  facilities  for  treating  hip  disease  arise.  I  happen  to  have 
performed  excision  seven  times  for  such  cases  ;  of  these  six  recovered 
with  sound  and  useful  limbs,  but  in  one,  a  lad  of  18,  in  which  the 
sinuses  had  closed  some  years  before  the  operation,  I  should  now  prefer 
to  improve  the  condition  of  the  limb  by  a  Gant's  osteotoni}'  and  di\^sion 
of  the  contracted  sartorius,  tensor  vaginas,  and  adductor  longus.  These 
patients  seem  to  me  to  bear  excision  well,  this  being  probably  due  to 
their  having  good  ^'itality,  as  shown  by  their  survival,  and  the  amount 
of  repair.  Further,  in  running  successfully  the  gauntlet  of  the  disease, 
they  have  escaped  the  dangers  of  lardaceous  and  general  tubercular 
trouble.  The  surgeon  here  must,  if  he  excise,  be  prepared  for  a  good 
deal  of  trouble  in  dislodging  the  displaced  head,  after  sawing  through 
its  neck,  owing  to  its  being  firmly  matted  down  by  old  adhesions. 

The  Condition  of  the  Limb.  Is  this  a  better  one  after  Excision 
or  after  a  Cure  by  Rest  ? 

Here,  again,  there  is  marked  divergence  of  opinion,  ^h\  Marsh  (loc. 
supra  cit..  p.  308)  is  of  opinion  that  "  the  limb  after  excision  of  either 
the  hip  or  the  knee  is  usually  very  inferior  to  the  average  limb  that  is 
obtained  after  recovery  has  followed  the  treatment  by  rest."  Mr. 
Holmes  (Syst.  of  Surg.,  vol.  iii.  p.  757,  1883)  thinks  that,  while 
recovery  after  excision  of  the  hip -joint  is  very  complete  as  far  as  the 
movements  of  the  limb  are  concerned,  "the  shortening  is  generally 
greater  than  after  the  spontaneous  cure,  and  the  limb  is  less  firm,  and, 
on  the  average,  less  useful."  The  Clinical  Society's  Committee  reported 
on  this  subject  that,  after  excision,  "movement  is  more  frequently 
present,  and  is  also  more  extensive,  but  that  patients  often  walk  more 
insecurely  and  with  a  considerable  limp,  while  the  limb,  after  treatment 
by  rest  and  extension,  though  frequentl}^  more  or  less  fixed,  is  more 
firm  and  useful  for  the  purposes  of  progression."  While  feeling  assured 
that  the  resulting  usefulness  in  some  cases  treated  by  excision  far 
surpasses  the  best  results  obtained  by  rest.  I  consider  that  the  arermje 
result  obtained  by  rest  is  superior  to  that  following  excision,  and  that 
VOL.  II.  :;8 


594  OPERATIONS  ON  THE  LOWER  EXTREMITY. 

this  is  increasingly  marked  after  childhood,  the  limb,  especially  in 
adolescents  recovering  after  excision,  being  very  often  flail-like  and 
useless.* 

On  the  other  hand,  Mr.  Wright,  whose  large  experience  on  this 
subject  has  already  been  referred  to,  has  come  to  the  conclusion  [loc. 
supra  cit.,  p.  126)  that  "  excision  gives  a  better  limb  than  the  average 
result  obtained  without  operation;"  and  again  (p.  114):  "In  my  own 
experience,  useless,  flail-like  joints  are  exceedingly  rare,  and  limited  to 
those  cases  where  the  excision  was  performed  in  very  late  stages  of  the 
disease  ;  the  powerless  condition  is,  I  take  it,  the  result  of  the  disease, 
not  of  the  operation."  With  regard  to  the  two  conditions  which  chiefly 
interfere  with  the  usefulness  of  the  limb  after  hip-excision — viz.,  a  flail- 
like state,  and  shortening — Mr.  Wright's  opinion  on  the  former  has 
already  been  given.  With  regard  to  the  latter,  he  considers  (p.  108), 
that  "  though  some  shortening  must  necessarily  result,  this  arises  mainly 

from  the  weight  being  borne  upon  the  limb  prematurely Growth 

in  length  of  the  femur  takes  place  almost  entirely  at  its  lower  epiphysial 
line,  hence  the  loss  of  length  or  true  shoi'tening  is  only  the  distance 
from  the  line  of  section  of  the  top  of  the  head,  coupled  with  such  arrest 
of  growth  as  may  result  from  impaired  nutrition,  this  last  being,  of 
course,  a  very  inconstant  c|uantity."  t 

Mr.  Barker,  in  giving  an  analysis  of  the  after-historj^  of  forty-one 
cases  of  excision  by  the  anterior  method  (Lancet,  1900,  vol.  i.  p.  1499), 
also  speaks  favourably  of  the  final  result.  He  says  :  "  As  to  functions 
of  the  limbs  oi^erated  on,  as  seen  (in  all  cases  but  two)  years  after,  they 
were  excellent." 

Conditions  of  Success  in  Excision  of  the  Hip. — Amongst  these 
are:  i.  Age.  I  consider  the  best  six  to  fourteen.  After  eighteen 
excision  should  rarely  be  performed,  Furneaux  Jordan's  amputation 
taking  its  place.  Mr.  Wright  (p.  126)  thinks  that  after  fifteen  excision 
should  be  rejected  in  favour  of  amputation.  2.  Absence  of  lardaceous 
disease.  I  cannot  agree  with  the  conclusion  of  the  Clinical  Society's 
Committee  (loc.  supra  cit.,  p.  233),  that  excision  is  called  for,  "  when,  in 
a  case  of  suppuration,  enlargement  of  the  liver  and  albuminuria,  indi- 
cating the  presence  of  degeneration  of  the  viscera,  is  detected."  Exci- 
sion should  be  performed,  in  my  opinion,  only  before  the  appearance  of 
lardaceous  disease.  When  there  is  evidence  of  this  condition  having  set 
in,  especially  in  the  kidneys  or  intestine,  amputation  is  to  be  preferred. 
3.  Absence  of  advancing  mischief  in  other  joints,  or  of  tubercular 
lesions  in  the  viscera — e.g.,  the  lung.  4.  The  disease  must  be  removed 
as  entirely  as  possible.  Thus,  in  the  femur  at  least,  the  section  must 
pass  below  all  foci  of  disease.  All  sinuses  should  also  be  scraped  out. 
5.  Adequate  drainage.  6.  Careful  after-treatment,  the  wound  being 
kei^t  aseptic.  7.  The  patient  must  not  be  kept  too  long  on  his  back  in 
hospital  air. 

*  Prof.  Bruns,  of  Tubingen  (loc.  infra  cit.'),  is  of  opinion  that  in  the  preservation  of 
function  the  balance  is  greatly  in  favour  of  the  conservative  treatment  as  opposed 
to  resection. 

t  On  this  matter  Mr.  Wright  quotes  Prof.  Ollier's  (Rev.  de  Chir.,  1881  ;  Annals  of 
Surg.,  Jan.,  1886)  estimate  that,  up  to  five  years  of  age,  the  growth  of  the  femur  takes 
place  about  equally  at  its  two  ends  ;  that,  after  five,  the  rate  of  growth  of  the  lower 
end  increases  rapidly  till  it  becomes  three  times  that  of  the  upper. 


EXCISION  OF  THE   HIP.  595 

B.   Gunshot  Injuries. 

Excision  of  the  Hip -joint  for  Gunshot  Injuries,  contrasted  with 
Conservative    Treatment,  and    Amputation    at   the    Hip-joint. — For 

the  sake  of  convenience  it  will  be  well  to  take  the  above  three  plans  of 
treatment  of  gunshot  injuries  of  the  hip  together.  As  before,  I  shall 
avail  myself  of  the  laborious  researches  and  the  unrivalled  authority  on 
this  subject  of  Dr.  Otis.  He  writes  (Med.  mtd  Surg.  Hist,  of  the  War  of 
the  Rebellion,  pt.  iii.  p.  165)  that  the  evidence  collected  during  the 
American  war  shows  that  "  of  the  cases  of  undoubted  intra-capsular 
shot-fracture  of  the  hip  treated  by  conservation,  98*8  per  cent,  had  a 
fatal  termination,  that  in  sixty-six  cases  treated  by  excision,  the  fatality 
was  90'9  per  cent.,  and  that  in  sixty-six  cases  treated  by  exarticulation, 
it  was  83"3  per  cent.  ;  but  from  these  results  it  should  not  be  concluded 
that  operative  interference  was  always  indicated,  and  that  amputation 
was  preferable  to  excision.  On  p.  121  of  Circidar  No.  2,  I  have  already 
pointed  out  that  the  question  as  to  the  most  eligible  treatment  of  shot 
injuries  of  the  hip-joint  is  not  susceptible  of  a  purely  arithmetical 
solution,  and  that  the  variety  of  the  conditions  under  which  the  patients 
are  placed,  the  diversity  in  the  extent  of  their  injuries,  and  the  inevitable 
imperfection  of  all  surgical  records,  forbid  any  such  rigorous  compainson. 
No  less  than  nine  of  the  sixty-six  cases  of  excision  were  complicated 
with  such  lesions  of  the  pelvic  walls  and  viscera  as  made  any  operative 
interference  useless ;  among  the  sixty-six  coxo-femoral  amputations, 
probably  all  successful  cases  have  been  recorded,  while  some  fatal  cases 
may  remain  unpublished,  and  in  the  304  cases  treated  by  conservation, 
the  correctness  of  the  diagnosis  may  be  questioned  in  many  instances. 
The  character  of  the  injury  must  determine  the  choice  of  treatment ; 
but  the  general  rules  regarding  shot  wounds  of  the  hip-joint  laid  down 
in  Circular  2  are  uncontroverted  :  that  expectant  treatment  is  to  be  con- 
demned in  all  cases  in  which  the  diagnosis  of  direct  injmy  to  the 
articulation  can  be  clearly  established,"  that  "  primary  excisions  of  the 
head  or  upper  extremity  of  the  femur  should  be  performed  in  all  uncom- 
plicated cases  of  shot  fracture  of  the  head  or  neck  ; "  that  "  intermediary 
excisions  are  indicated  in  similar  cases  where  the  diagnosis  is  not  made 
out  till  late; "  that  "  secondary  excisions  are  demanded  by  caries  of  the 
head  of  the  femur  or  secondary  involvement  of  the  joint ;  "  that  ampu- 
tation should  be  performed — "  I.  When  the  thigh  is  torn  off,  or  the 
upper  extremity  of  the  femur  comminuted  with  great  laceration  of  the 
soft  parts,  in  such  proximity  to  the  trunk  that  amputation  in  continuity 
is  impracticable.  2.  When  a  fracture  of  the  head,  neck,  or  trochanters  of 
the  femur  is  complicated  with  a  wound  of  the  femoral  vessels.  3.  When 
a  gunshot  fracture  involving  the  hip-joint  is  complicated  b}^  a  severe 
compound  fracture  of  the  limb  lower  down,  or  by  a  wound  of  the 
knee-joint." 

It  is  possible  that  Dr.  Otis's  opinion  as  to  the  uselessness  of  expectant 
treatment  in  gunshot  injuries  of  the  hip-joint  will  need  alteration  in  the 
future — i.e.,  Prof.  Langenbeck,*  from  his  experience  in  the  Franco- 
German  war,  considered  that  the  expectant  treatment  gave  a  larger  pro- 
portion of  recoveries  than  excision,  and  still  more  than  amputation,  and 
advised  that  the  expectant  method   should  always  be  resorted  to  save 

*  Arch  f.  Klin.  Ckir.,  1874,  Bd.  xvi.  S.  309-316.  The  recoveries  seem  to  have  been 
twenty-five  out  of  eighty-eight  cases  so  treated. 


596  OPERATIONS  ON  THE  LOWER  EXTREMITY. 

when  disarticulation  is  rendered  inevitable  b}"  the  destruction  and 
shattering  of  the  limb.  Sir  T.  Longmore  (Syst.of  Surg.,  vol.  i.  p.  561), 
thinks  that  this  question  must  be  held  to  be  still  "  suh  judice,  and 
surgeons  must  wait  for  still  more  extended  experience  under  modern 
improved  methods  of  treatment,  before  any  rule  can  be  accepted  as 
having  yet  been  established  on  this  grave  question." 

Examining  into  the  dates  at  which  the  excisions  of  the  hip  were 
performed,  Dr.  Otis  (loc.  supra  cit.,  p.  126)  gives  the  mortality  rate  at 
93  per  cent,  for  the  primary,  96*6  per  cent,  for  the  intermediary,  and 
63*4  per  cent,  for  the  secondary  operations.  Thus,  "the  excisions  and 
amputations  practised  during  the  intermediaiy  or  inflammatory  stage 
are  by  far  the  most  dangerous,  and  should  never  be  performed  except 
as  compulsory  operations." 

As  to  the  dates  of  the  exarticulations  of  the  254  cases,  there  were 
82  primar}^,  with  75  deaths  (9r4  per  cent,  mortality)  ;  55  intermediary, 
with  52  deaths  (94*5  per  cent.);  40  secondary,  with  33  deaths  (82-5  per 
cent.) ;  re-amputations,  with  4  deaths  (36*3  per  cent.).  Dr.  Otis  shows 
from  these  statistics  that  "intermediary'  operations  offer  the  least 
chance  of  recovery,  that  the  results  of  primary'  operations  are  more 
favourable ;  that  secondary  exarticulations  give  one  recovery  in  twelve 
cases ;  and  that  of  the  instances  of  re-amputation  one  in  about  three 
proves  successful.  .  .  .  Unless  the  nature  of  the  injury  is  such  that  the 
operation  can  be  delayed  till  the  secondary  period,  it  is  better  that  it 
should  be  done  at  once,  although  it  would  appear  that  the  dire  results 
of  amputations  at  the  hip  performed  during  the  Schleswig-Holstein  war 
of  1864,  the  Austro-Prussian  war  of  1866,  and  the  Franco-Prussian 
war  1 8707 1,  have  had  a  tendency  to  raise  doubts  regarding  the 
expediency  of,  especiall}'  the  primary,  exarticulation  of  the  hip." 

Very  probably  the  results  of  these  injuries  in  the  Boer  war,  when 
published,  will  be  found  to  differ  widely  from  those  given  above;  in 
consequence  chiefly  of  the  difference  in  the  projectile  and  of  the  greatly 
diminished  frequency  of  septic  infection. 

Operation. — Two  will  be  described  here  :  A.  By  Posterior  Incision  ; 
B.  By  Anterior  Incision. 

A.  Posterior  Incision  (Figs.  234,235). — The  chief  advantage  of  this 
is  its  better  drainage,  a  point  which  is  of  less  importance  nowadays,  and 
which  no  longer  outweighs,  in  m}'  opinion,  the  smaller  interference 
with  muscles  entailed  by  the  incision  in  front  (p.  599). 

While  the  patient  is  being  brought  under  ether,  a  stirrup  is  applied 
if  weight-extension  is  to  be  made.*  The  child  being  rolled  over  on  to 
his  sound  side,  and  the  parts  thoroughly-  cleansed,  the  surgeon  stands 
usually  outside  the  limb,  the  patient's  body  being  in  either  case  placed 
conveniently  at  the  edge  of  the  table,  one  assistant  supporting  the  limb, 
while  another  is  opposite  to  the  surgeon.  An  incision,  about  three 
inches  and  a  half  long,!  is  now  made  over  the  middle  J  of  the  great 
trochanter,  commencing  about  midway  between  the  top  of  this  bone 

*  There  is  no  occasion  to  apply  an  Esraarch's  bandage  above  the  wound ;  and 
rendering  the  limb  evascular,  save  by  elevation,  is  often  rendered  impossible  by 
the  presence  of  an  abscess  or  sinuses. 

t  This  is  usually  suflacient  in  a  child.  But  it  must  be  always  remembered  that  a 
small  wound,  by  giving  insufficient  room,  leads  to  bruising  and  difficulty. 

t  The  advantage  of  going  as  far  forward  as  this  is,  that  the  fleshy  and  vascular 
IKirts  of  the  muscles  attached  to  the  Lrreat  trochanter  are  better  avoided. 


EXCISION  OF  THE  HIP.  597 

and  the  posterior  superior  spine,  and  ending  over  the  shaft,  just  below 
the  trochanter.  The  incision  shoukl  curve  slightl}-  forwards  and  pass 
down  to  bone  or  cartilage,  as  the  case  may  be,  at  once.  Any  bleeding 
vessels  having  been  secured,  the  exact  position  of  the  head  and  neck  is 
now  made  out  by  the  finger,  aided  by  an  assistant  rotating  the  limb. 
A  second  incision  opens  the  capsule  freely.  With  a  periosteal  elevator, 
aided   by  a  knife,   the   muscles  attached  to  the  great  trochanter  are 

Fig.  234- 


Eesec'tion  of  the  head  of  the  femur  by  the  posterior  iucisiou.  The  thigh  is 
fiexed  to  an  angle  of  45°.  The  gUiticus  maximus  has  been  divided,  allowing  the 
great  trochanter  to  come  into  view.  The  retractor  draws  aside  the  skin,  the 
ui^per  part  of  the  glutseus  uiaxiuius,  and  the  medius.  Below  it  is  the  pyri- 
forrais.     (Farabeuf.) 

detached,  the  cartilage  in  young  subjects  peeling  off  with  them  in 
one  or  more  pieces.  The  finger  is  now  passed  round  the  neck  of  the 
femur  and  the  soft  parts,  including  the  periosteum,  detached  as  much 
as  possible  on  the  inner  side.  The  finger,  now  feeling  that  the  upper 
part  of  the  trochanter  and  the  neck  of  the  bone  are  free,  and  protecting 
the  soft  parts  on  the  inner  side,  the  bone  is  sawn  through  just  below  the 
top  of  the  trochanter  with  an  osteotomy,  metacarpal,  or  keyhole  saw.* 

*  The  section  of  the  bone  should  always  be  made  while  this  is  i)i  tiitii.  The  plan  of 
<lislocating  the  head  by  adducting  the  limb,  and  then  sawing  it  off,  disturbs  the  parts 
more,  and  runs  the  risk  of  fracturing  the  wasted  femur  of  a  little  child,  an  accident 
which  I  have  seen  occur  in  the  hands  of  a  very  careful  operator.  Mr.  Wright  (^loc. 
xiipra  rit.,  p.  loi)  states  that  he  had  one  case  among  his  earlier  operations,  and  that 
he  has  also  separated  the  lower  epiphysis  in  an  infant  while  manipulating  the  femur 
during  incision  of  the  joint.  He  points  out  another  objection — viz.,  the  ease  with 
which  the  periosteum  may  be  stripped  off  if  the  head  of  the  b-^ne  is  thrust  out. 


598 


OPERATIONS  OX  THE  LO^^'ER  EXTREMITY. 


This  division  should  be  thoroughly  and  cleanl}^  effected  without  splinter- 
ing. If  it  be  preferred,  in  addition  to  the  protection  of  the  finger  on 
the  inner  side,  a  blunt  dissector  may  be  passed  behind  the  bone,  but 
this  is  not  essential :  retraction  will  protect  the  lips  of  the  wound  from 
the  saw.  With  the  aid  of  the  finger  and  an  elevator,  or  with  a  lion- 
forceps,  the  head  and  neck  of  the  bone  are  levered  out  of  the  acetabulum, 
this  being  often  attended  with  some  difficulty  unless  the  capsule  has 
been  very  freely  opened.  The  ligamentum  teres  is  probably  distroyed ; 
if  not,  it  must  be  divided.  The  acetabulum  is  then  examined,  and,  if 
merely  roughened,  left  alone  ;  if  pitting  or  erosion  be  present,  gouging 
must  be  resorted  to.  Any  sequestra  present  must  be  removed.  If  the 
acetabulum  is  perforated,  and  pus  present  on  its  pelvic  aspect,  free  exit 

Fig.  235. 


Excision  of  the  head  of  the  right  femur.  Separation  of  the  capsule  and 
periosteum  has  been  thoroughly  performed.  G,  Gluteus  maximus.  M, 
Medius.  C,  The  capsule  opened.  P,  Pyramidalis.  T,  Great  trochanter. 
The  upper  retractor  raises  the  upper  lip  of  the  glutseus  maximus,  the 
medius,  the  minimus  which  is  hidden,  and  the  capsule.  The  lower  retrac- 
tor depresses  the  pyramidalis  and  the  capsule.     (Farabeuf.) 


must   be  provided   by  means    of  a   gouge    or    small    trephine,   and  a 
drainage-tube  passed  througli. 

The  inner  surface  of  the  capsule  and  all  abscess  cavities  must  now  be 
thoroughly  scraped  and  irrigated  by  means  of  a  flushing  spoon,  as 
described  below,  until  all  granulation  tissue  and  caseous  debris  have  been 
renjoved.  If  sinuses  are  present,  these  must  either  be  excised  or  care- 
fullj-  curetted  according  to  their  position  and  extent.  Hjemorrhage  is 
usuall}'  very  slight,  and  with  the  exception  of  a  few  vessels,  which  may 


F.XCrSIOX   OF  THE   HIP.  599 

be  caught  with  forceps,  usual!}-  consists  of  a  general  oozing.  This  will 
usually  be  stopped  by  the  hot  irrigating  fluid ;  if,  however,  it  is 
troublesome,  the  cavity  may  be  packed  with  gauze. 

Drainage,  either  by  means  of  iodoform  gauze  or  a  tube,  will  be 
necessary  in  nearly  all  cases.  In  a  few,  however,  where  no  sinuses 
exist  and  there  is  no  intra-pelvic  abscess,  and  where  all  oozing  has  been 
arrested,  a  little  sterilised  iodoform  may  be  rubbed  in  and  the  wound 
closed  with  sutures.  The  dressings  must  be  carefully  applied  and  firm 
pressure  used  to  prevent  oozing. 

Site  of  Section  of  the  Femv/r. — Having  tried  both,  I  think  that  the 
section  through  the  great  trochanter  (i.e.,  just  below  its  upper  margin) 
is  preferable  to  one  above  it  [i.e.,  through  the  neck).  The  latter  has 
the  advantages  of  disturbing  and  damaging  the  attachments  of  muscles 
much  less,  and  thus  leads  to  more  rapid  healing  and  far  gi'eater  mobility 
of  the  limb.  These,  however,  are  outweighed  by  the  disadvantage 
which  leaving  such  a  large  piece  of  bone  as  the  trochanter  entails — 
viz..  that,  after  healing,  this  process  gets  drawn  up  against  the  scar  and 
constantly  frets  it.*  It  is  also  said  to  check  the  escape  of  discharges, 
and  to  render  the  patient  liable  to  persistence  or  recurrence  of  the 
disease.  I  am  doubtful  as  to  the  last  two,  but  the  first  is  absolutely 
certain. 

B.  ^h\  A.  E.  Barker,!  has  shown  what  excellent  results  the  anterior 
method  can  give.  In  his  Hunterian  Lectures  (Brit.  Med.  Joarn.,  1888, 
vol.  i.  p.  1326)  he  advocated  the  use  of  this  mode  of  excision  in  the 
earl}-  stage  of  hip  disease.  In  later  papers  (ibidj.,  1888,  vol.  ii.  p.  1337? 
and  1890,  vol.  ii.  p.  1009)  he  published  some  most  successful  cases  thus 
treated  in  later  stages,  where  other  means  had  failed,  and  abscesses 
were  threatening  to  burst.  He  advocates  the  anterior  incision  on  the 
following  grounds  especially,  fi)  the  interference  with  the  muscles  is 
practically  nil ;  (2)  the  patient  can  thus  be  treated  and  his  wound 
dressed  much  more  convenient!}" — e.g.,  with  a  Thomas's  splint ;  (3) 
primary  union  can  be  secured  if  the  following  most  essential  points 
are  strictly  attended  to ;  (a)  tlie  Avhole  of  tlie  diseased  structures  must 
be  removed ;  (h)  perfect  asepsis  must  be  secured ;  (c)  all  oozing 
must  be  checked,  and  the  wound  kept  dry  by  well-applied  dressings ; 
(d)  absolute  rest  must  be  maintained  during  healing.  Witli  regard  to 
the  oljjection  wliicli  lias  usually  been  considered  to  be  fatal  to  the 
anterior  incision,  %'iz.,  the  insufficient  drainage  which  it  gives — Mr. 
Barlver  replies  that  the  incision,  tliough  anterior,  is  perfectly  adequate 
for    drainage,    (i)    because    tlie    discliarges    are,    if   tlie    above-given 


*  About  fourteen  years  ago  I  made  use  of  this  method  in  one  case,  sawing  the  bone 
through  the  neck  and  leaving  the  trochanter  entire.  A  rapid  recovery  took  place,  and 
the  boy  quickly  regained  power  over  the  limb.  He  has  long  been  able  to  run  and 
climb  like  other  lads,  and  the  movements  of  flexion,  extension,  abduction,  and 
adduction  are  extraordinarily  perfect.  He  has,  however,  been  under  my  care  on 
several  occasions  for  superficial  ulceration  of  the  scar,  which  is  fretted  by  the  very 
prominent  upper  margin  of  the  immediately  subjacent  trochanter. 

t  Mr.  K.  W.  Parker  QC'lin.  Soc.  Trans.,  vol.  viii.  p.  loS)  recommended  this  method  as 
interfering  less  with  the  muscles  and  the  blood-supply  of  the  joint.  Hiiter  was,  I 
hplieve,  reaUj^  the  first  to  use  this  incision,  draining  the  joint  by  a  counter-puncture 
at  the  back. 


6oo 


OPERATIONS  ON  THE  LOWER  EXTREMITY. 


precautions  are  duly  followed,  very  small  in  quantity,  "  little  more 
than  odourless  serum,  which  ought  never  to  become  truly  purulent;" 
(2)  "  if  all  the  tubercular  tissue  is  removed,  a  clean-walled  cavity  is  left, 
most  of  which  is  quite  capable  of  healing  by  first  intention,  when  its 
different  surfaces  are  brought  into  close  contact  b}^  firm  pressure.    And, 

in  these  cases,  the  head  of  the  bone 


Fig.  236. 


being  removed  and  the  acetabulum 


quite  clean,  the  ciit  surface  of  the 
neck  of  the  femur  can  be  brought 
close  up  to  the  latter,  so  that  al- 
though there  is  potentially  a  large 
space  in  the  field  of  operation,  there 
ought  to  be  actually  little  or  no 
cavity  left,  if  pressure  has  been 
properly  applied  from  the  first." 

Of  the  conditions  which  it  is 
absolutely  necessary  to  secure  for 
the  obtaining  of  primary  union,  and 
the  success  of  the  anterior  incision, 
the  first — that  the  whole  of  the 
diseased  structures  must  be  removed 
—  is  b}^  far  the  most  impoi'tant.  It 
is  also,  from  my  experience,  the  most 
difficult  to  secure.  G.  A.  Wright 
(Brit.  Med.  Journ.,  1888,  vol.  ii.  p. 
1338),  speaking  at  the  discussion  on 
one  of  Mr.  Barker's  papers,  said  that 
he  had  found  the  entire  removal  of 
the  morbid  tissues  practically  im- 
\  \        ^  \  1  possible    either   by  the  anterior   in- 

\  \        \  \  I  cision   which    he    used    occasionally, 

or  by  the  posterior.  Only  little  foci 
of  disease  might  be  left,  but  they 
were  apt  to  suppurate  when  some 
fall  or  accident  gave  them  the  op- 
portunity. On  this  point  we  must 
wait  for  the  light  which  further 
carefully-watched  and  reported  cases 
alone  can  give  us. 

Operation. — The  patient  being  on 
his  back,  with  the  limb  extended, 
and  the  parts  duly  cleansed,  the  sur- 
geon standing,  in  the  case  of  either 
limb,  on  the  right  side,  makes  an  incision  three  to  four  inches  long, 
starting  half  an  inch  below  the  anterior  superior  spine,  downwards  and 
slightly  inwards,  between  the  tensor  vagina  and  glutaei  externally  and 
the  sartorius  and  rectus  internally.  The  iipper  part  of  this  incision 
should  pass  down  to  the  capsule  at  once,  the  lower  third  shoiild  divide 
skin  only.  The  interval  between  the  above-named  muscles  is  now 
thoroughly  opened  up  and  the  wound  retracted,  so  that  the  anterior 
surface  of  the  capsule  is  exposed.  This  must  now  be  opened,  and  with 
the  limb  flexed,  the  left  index  finger  is  passed  into  the  joint.     As  the 


Anterior  incision  for  excision  of  the  hip. 
(Mac  Cormac.) 


EXCISION'  OK  THE  HIP.  6oi 

difficulty  which  is  sometimes  experienced  in  removing  the  head  ^is 
usually  due  to  an  insufficient  division  of  the  capsule,  this  is  now 
further  incised  with  scissors,  the  left  index  finger  being  used  as  a 
guide.  An  aseptic  finger  now  examines  the  condition  of  the  joint. 
The  wound  being  opened  by  retractors,  a  narrow-bladed  saw  is  intro- 
duced into  the  upper  part,  in  the  direction  of  the  wound,  and  with  as 
little  damage  to  the  soft  parts  as  possible,  and  the  femur  sawn  through 
across  the  top  of  the  great  trochanter,  or  through  the  neck. 

The  advantages  and  disadvantages  of  the  latter  step  have  been 
already  given  at  p.  599.  In  a  case  at  all  advanced  there  will  always 
be  a  risk  that  a  section  as  high  up  as  this  will  expose  diseased  bone. 
The  head  of  the  femur  is  now  extracted  and  the  acetabulum  treated 
by  the  means  given  at  p.  598.  Every  atom  of  diseased  structure  must 
now  be  removed,  especial  care  being  taken  to  clear  out  any  caseating 
abscesses  communicating  with  the  joint.  All  this  should  be  done  with 
as  little  violence  as  possible  to  the  surrounding  tissues,  so  that  none  of 
the  tubercular  debris  be  forced  into  the  fresh-cut  surfaces.  The  best 
instrument  for  removing  the  disease  thoroughly  is  Mr.  Barker's  "flush- 
ing gouge"  (Fig.  237).     This  has  a  cutting  scoop-like  edge,  is  perfo- 


Barker's  Hushing  gouge.      Down's  Catalogue.) 

rated,  and  to  its  belt  is  attached  tubing  which  communicates  with  an 
irrigating  can.  By  this  means  boiled  water  (F.  105°)  is  kept  flowing- 
through  the  area  of  operation,  carrying  away  the  debris  of  disease 
whether  from  abscess  cavities,  the  joint,  or  the  surface  of  the  aceta- 
bulum, if  diseased,  and  with  it  all  blood,  while  at  the  same  time  it 
arrests  heemorrhage.  When  every  part  of  the  field  of  operation  has 
been  gouged  and  scraped  clear  of  all  tubercular  material,  and  the  water 
runs  clear,  the  cavity  is  dried  out  with  carbolised  sponges,  one  or  two 
of  which  are  left  in  it  until  all  the  sutures  are  in  sitti.  These  should 
dip  deeply,  and  be  placed  close  together.  Just  before  they  are  tied, 
the  sponges  are  removed,  and  with  them  the  last  trace  of  moisture. 
The  wound  is  then  filled  up  with  iodoform  emulsion,  and  the  sutures 
are  tied,  as  much  of  the  emulsion  as  will  come  away  being  squeezed 
out  at  the  last  moment.  Graduated  even  pressure  is  then  applied  by 
the  dressing  and  bandages,  so  that  the  walls  of  the  cavity  are  brought 
into  apposition,  and  the  remainder  of  the  neck  of  the  femur  secured 
in  the  acetabulum.  The  patient  is  then  placed  in  a  double  Thomas's 
splint.  If  sinuses  are  present,  and  the  joint  infected,  the  wound  must 
not  be  closed,  but  drainage  must  be  provided.  The  sinuses  having 
been  opened  up  and  thoroughly  curetted,  must  be  plugged  b}*  means 
of  strips  of  iodoform  gauze  passing  down  to  the  bottom. 

With  regard  to  the  after-treatment  I  would  urge  that  cases  of  hip 
excision  should  be  got  up  as  early  as  possible — i.e.,  at  the  end  of  six  or 
eight  weeks.     A  double  Thomas's   splint,  with  foot-pieces,  should  be 


6o2  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

applied  immediately  after  the  operation,  and  worn  for  a  period  of  from 
four  to  eight  months.  After  this  the  child  should  get  about  on  a 
patten  and  crutches,  swinging  the  affected  limb.  He  should  not  be 
allowed  to  use  this  for  upwards  of  a  year  after  the  operation.  If 
weight  is  borne  on  the  limb  earlier,  the  end  of  the  femur  is  pushed 
upwards  on  to  the  dorsum  ilii,  and  much  shortening  is  the  result. 
Mr.  Barker  has  allowed  some  of  his  cases  to  get  up  and  dispense 
with  a  splint  at  a  much  earlier  period.  I  think  the  above-given  dates 
better  suited  to  these  cases  of  excision  of  the  hip,  when  we  remember 
the  risks  to  which  they  are  exposed  by  their  rough-and-tumble  life 
when  they  leave  the  hospital. 

Usual  Causes  of  Failure  after  Excision  of  the  Hip. 

I.  Persistent  pelvic  disease.  2.  Chronic  osteo-myelitis  of  sawn  end 
of  femur.  3.  Suppuration  and  hectic.  4.  Lardaceous  disease.  5.  Tuber- 
cular conditions  elsewhere.  General  outbreak  of  tuberculosis.  6.  Disease 
of  the  opposite  femur. 

Bruns,  of  Tubingen  {Beitr.  z.  hlin.  Chir.,  vol.  xxii.  part  i.,  Tubingen, 
1894),  shows  from  carefully  recorded  cases  that  about  two-thirds  of 
the  deaths  after  resection  were  due  to  a  general  tuberculosis  or  tuber- 
culosis of  other  organs,  one-third  only  being  caused  by  suppuration 
and  its  sequelae,  septic  infection,  exhaustion,  or  amyloid  disease. 


CHAPTER    II. 

OPERATIVE   INTERFERENCE   IN   DISLOCATION 

OF   THE   HIP. 

Here  three  varieties  of  cases  have  to  be  considered: — I.  Traumatic 
Dislocations.  II.  Dislocation  from  Disease  (this  is  rather  a  partial 
•dislocation,  or  a  subluxation).     III.  Congenital  Dislocations. 

I.  Traumatic  Dislocation. — The  great  deformitv,  permanent  crip- 
pling, and  often  great  suffering  resulting  from  old  unreduced  disloca- 
tions of  the  hip,  abundantly  justify  resort  to  operation,  nowadays,  as 
long  as  it  is  understood  that  the  operation  may  be  a  severe  one,  and 
the  after-treatment  one  requiring  great  vigilance  on  the  part  of  the 
-surgeon. 

In  an  excellent  paper  (Ann.  of  Surg.,  Sept.  1894,  p.  319)  Dr.  M.  L. 
Harris,  of  Chicago,  publishes  an  instructive  case  of  his  own  and  twenty- 
four  others  which  he  has  collected.  From  these  he  draws  the  following 
conclusions  :  (i)  Owing  to  the  danger  of  fracturing  the  neck  of  the 
femur  (Arch.  f.  Mm.  CJiir.,  1885,  Bd.  xxxii.  S.  440);  of  laceration  of 
the  great  vessels  of  the  thigh  (Ann.  of  Simf.,  June  1892,  p.  425), — 
here,  in  an  attempt  to  reduce  by  manipulation  an  obturator  dislocation 
of  thirteen  weeks'  duration  in  an  adult,  a  fatal  tear  was  produced  at 
the  junction  of  the  superficial  and  deep  femoral  veins  ;  or  of  shock 
«and  death  {Uer.  (VOdlioii..  Sept.  1890),  the  application  of  gi^eat  force 
to  reduce  old  dislocations  of  the  hip  should  be  discontinued  in  favour 
of  freely  opening  the  joint  and  reducing  the  head  of  the  bone,  after 
the  method  used  by  Dr.  Harris  (vide  infra).  This  is  the  treatment 
which  gives  the  best  results.  (2)  That  subcutaneous  operations  in  old 
dislocations  are  without  benefit.  (3)  That  as  osteotomy  below  the 
great  trochanter  leaves  the  head  in  its  abnormal  position,  and  thus  fails 
to  relieve  the  pain  which  so  frequently  accompanies  these  old  disloca- 
tions, and  as  it  cannot  improve  the  limited  mobility  which  is  always 
present,  it  is  not  to  be  considered  in  any  way  an  operation  of  choice. 
(4)  Resection  is  only  to  be  thought  of  when  reduction  after  free 
^rthrotomy  fails. 

The  following  are  the  steps  of  the  operation  performed  by  Dr.  Harris 
in  his  case  of  dorsal  dislocation  of  nearly  four  months'  standing, 
in  which  repeated  and  prolonged  artempTs  at  reduction  liad  been 
made : 


604  OPERATIONS  ON  THE  LO^^■ER  EXTREMIT\. 

An  incision  about  fourteen  centimetres  in  length  was  made  in  front  '-•'  of  the  great 
trochanter  between  the  tensor  vaginae  femoris  and  the  glutteus  medius,  thus  leading 
directly  down  to  the  acetabulum  and  anterior  surface  of  the  head  and  neck  of  the 
femur.  As  was  expected,  the  acetabulum  was  found  iilled  with  a  tough,  adherent 
connective-tissue  proliferation  from  the  anterior  portion  of  the  capsular  ligament, 
which,  in  falling  over  the  cavity,  completely  closed  it.  On  cutting  through  the 
capsular  ligament,  the  head  of  the  bone  was  found  resting  on  the  posterior  and 
superior  edge  of  the  acetabulum  in  a  shallow  depression,  the  lining  of  which  had 
a  smooth  cartilaginous  feel.  Immediately  in  front  of  the  head  and  helping  to  till 
the  cotyloid  cavity  was  a  piece  of  bone,  curved  in  shape,  about  three  centimetres  in 
length  by  one  centimetre  in  depth  and  0-5  centimetre  in  width,  which  had  been 
detached  from  the  posterior  wall  of  the  acetabulum.  This  may  have  been  an  obstacle 
to  the  early  reduction  of  the  case.  The  head  of  the  bone  was  still  covered  with 
smooth  cartilage,  while  the  neck  had  acquired  new  firm  adhesion  to  all  the  surround- 
ing parts,  thus  producing  a  new  capsular  ligament. 

A  restoration  of  the  ligamentum  teres  could  not  be  demonstrated,  but  a  small 
portion  of  it  was  present  in  the  depression  in  the  head  when  this  was  turned  out 
of  its  new  joint.  The  adhesions  to  the  neck  were  divided,  and  all  the  muscular 
attachments  to  the  great  trochanter  and  shaft  as  far  down  as  the  lesser  trochanter 
were  separated  sub-periosteally  from  the  bone,  thus  liberating  the  entire  upper  end 
of  the  femur.  Attention  was  then  directed  to  the  acetabulum,  which,  by  means  of 
the  gouge  and  sharp  spoon,  was  freed  of  capsular  ligament  and  the  new  connective- 
tissue  formation.  The  cartilage  lining  the  bottom  of  the  cavity  was  found  to  be 
still  smooth.  The  head  of  the  bone,  however,  could  not  be  made  to  enter  the  aceta- 
bulum, which  seemed  too  small.  The  cavity  was  consequently  enlarged  somewhat 
posteriorly  with  the  gouge  and  mallet,  after  which,  by  considerable  exertion  and 
manipulation,  the  head  was  finally  retiirned  to  its  place,  and  the  leg  assumed  its 
normal  position.  The  wound  was  partly  stitched  wp,  and  the  rest  packed  with 
iodoform  gauze.  The  limb  was  placed  in  the  extended  position,  plaster  of  Paris  put 
on,  and  extension  applied.  The  operation  was  a  very  severe  one,  occupying  fully  two 
hours.  The  patient  suffered  considerably  from  shock,  although  the  loss  of  blood  was 
not  great.  Reaction  came  on  promptly,  and  the  progress  of  the  case  was  favourable 
from  the  start.  There  was  considerable  serous  drainage  from  the  wound  during  the 
first  few  days,  necessitating  rather  frequent  renewals  of  the  dressings.  In  three  weeks 
the  wound  was  closed,  but  in  another  week  a  small  collection  of  sero-pus  required 
evacuation  by  a  counter-puncture.  The  extension  was  continued  three  weeks.  Six 
weeks  from  the  time  of  the  operation  the  patient  was  allowed  up  on  crutches.  In 
three  months  he  could  walk  with  a  cane  without  pain  in  the  hip.  There  was  active 
motion  in  all  directions — tiexion,  abduction,  adduction,  and  rotation,  which,  though 
limited,  were  daily  increasing. 

II.  Dislocation  fko.m  Disease. — This  lia^  been  referred  to  at  p.  593. 

III.  Congenital  Dislocations. — Operative  interference  in  this  con- 
dition should  not  be  undertaken  unless  the  bloodless  method  of  re- 
position by  manipulationf  has  been  given  a  fair  trial,  and  has  failed. 
Even  then  the  advisability  of  operative  interference  here  is  still  much 
disputed.  When  we  consider  the  condition  of  the  parts  affected, 
especially  the  shallow,  ill-developed  acetabulum,  and  the  altered 
flattened  head,  we  can  easily  understand  the  difficulty  which  has 
been    met    with,   in    getting    the    head    into,   and    retaining    it    in,    a 

*  In  a  case  of  traumatic  tlorsal  dislocation  in  a  boy,  aged  7,  reduced  after  five 
months  by  the  open  method,  and  brought  by  Dr.  Spencer  before  the  Clinical  Society, 
Feb.  8,  1895,  a  long  anterior  incision  showed  the  acetabulum  to  be  filled  with  dense 
fibrous  tissue.  It  is  stated  that  the  acetabulum  could  not  have  been  reached  by  a 
posterior  incision  without  resecting  the  head  of  the  bone. 

f  The  best  method  to  employ  is  the  Paci-Lorenz,  a  detailed  account  of  which  wiE 
be  found  in  the  Medical  Annual,  1898. 


DISLOCATIONS  OF  THE  HIP.  605 

satisfactory  position.  Certainly  the  results  which  have  been  attained 
either  in  England  or  abroad  cannot  be  considered  to  be  satisfactory-. 
Moreover,  it  is  equally  certain  that  whatever  benefit  results  is  to  be 
attained  only  at  considerable  risk  (r?V/e  infra),  and  that  the  amount 
claimed  is  sometimes  open  to  dispute.*  Finalh",  the  fact  that  Hoffa 
has  practically  abandoned  his  own  operation  speaks  for  itself. 

As  long  as  the  technique  of  these  operations  requires  so  much  inter- 
ference with  the  parts,  as  long  as  the  risks  of  sepsis,  shock,  &c.,  are 
so  great,  no  operative  steps  should  be  undertaken  unless  the  risks  and 
the  results  have  been  fully  put  before  the  friends. 

Choice  of  Operations. — If  an  operation  has  been  decided  upon, 
Hoffa'sf  operation  of  division  of  the  retaining  shortened  structures 
and  replacement  of  the  head  of  the  bone  in  the  acetabulum  (which 
should  be  deepened)  may  be  performed,  or  a  new  acetabulum  may 
be  made  in  children  under  10.  In  older  patients,  e.g.,  10  to  16, 
if  the  deformity  is  really  severe  and  disabling,  Kirmisson'st  sub- 
trochanteric osteotomy  with  subcutaneous  division  of  the  adductors 
may  l'>e  tried. 

Operation. — The  following  account  of  Hoffa's  operation  is  taken  from 
an  article  by  Dr.  T.  H.  Myers  (Ann.  of  Surg.,  Aug.  i894,§  p.  144) : 

Opening  the  joint  by  Langenbeck's  incision,  division  of  the  capsule 
at  its  insertion  in  the  neck  of  the  femur,  and  sub-periosteal  freeing  of 
the  great  trochanter  from  all  the  muscles  attached  to  it,  are  the  first 
steps.  In  patients  under  five  years  old  it  is  then  almost  always  possible 
by  flexion  of  the  thigh  and  direct  pressure  upon  the  head  to  bring  this 
into  the  old  acetabulum.  The  hip  and  knee  now  are  often  seen  to  be 
flexed.  HoSa  overcomes  this  in  young  children  by  holding  the  head 
firmly  in  the  acetabulum  while  an  assistant  gradually  extends  the 
leg  on  the  thigh,  so  stretching  the  biceps,  semi-membranosus.  and 
semi-tendinosus.  This  is  accomplished  in  three  to  five  minutes.  In 
older  children,  six  years  and  upwards,  it  is  generally  better  to  divide 
these  muscles,  and  this  is  done  before  opening  the  joint.  Hofia  has 
adopted  Lorenz's  recommendation  of  dividing  them  at  the  tuber  ischii. 

The  limb  is  now  abducted,  and  the  adductors  subcutaneously  divided, 
then  hyper-extended  and  the  soft  parts  attached  to  the  anterior 
superior  spine  of  the  ilium,  and  the  fascia  lata,  divided  by  the  open 
method  so  as  to  control  better  the  haemorrhage.     These   wounds  are 


*  See  a  case  brought  before  the  Clinical  Society  and  the  remarks  made  at  the 
discussion  (^Brit.  Med.  Jonrn.,  vol.  i.  1895.  p.  365). 

t  Hoffa's  operation  was  first  described.  April.  1890,  Verhand.  Deutsck.  Gtsell- 
schaft  f.  Chir.,  p.  944.  He  is  stated  (^Ann.  of  Svrg.,  Aug.  1894,  P-  145)  to  have 
operated  seventy-fire  times.  a,n6.  is  clearly  an  enthusiast.  He  lavs  great  stress  on  the 
age.  The  younger  the  child,  the  better  the  result.  This  is  readily  intelligible, 
but  the  increased  risks  after  operation  (vide  infra)  at  this  early  age  must  not  be 
forgotten. 

X  Ri'Viic  d'Orthopedie,  No.  2,  1894. 

y^  Hoffa  makes  use  of  a  posterior  incision,  as  he  believes  that  the  structures  which 
chiefly  require  division  are  the  muscles  attached  to  the  great  trochanter  and  tuber 
ischii.  Lorenz  and  others,  who  believe  that  it  is  the  Y  ligament  which  is  the  chief 
obstacle  to  reduction,  recommend  the  anterior  incision.  When  this  is  made  use  of, 
another  running  transversely  outwards  may  be  needed  to  give  access  to  the 
acetabulum. 


6o6  OPEEATIO>'S  ON  THE   LOWEK  EXTREMITY. 

now  dressed,  and  the  joint  is  then  opened  as  described  above.  The 
head  must  be  freed  so  completely  that  it  can  readily  be  brought  out 
of  the  wound.  Hoffa  has  never  seen  any  necrosis  of  the  head  follow 
this  free  division.  The  ligamentum  teres,  if  present,  must  be  ex- 
tirpated, and  the  insertion  of  the  capsule  into  the  neck  freely 
divided.  A  sharp  Volkmann's  spoon,  bayonet-shaped,  is  now  giiided 
by  the  index-finger  to  the  acetabulum,  and  the  fatty  tissue  and  cartilage 
and  a  good  deal  of  spongy  tissue  are  scraped  out,  taking  care  to 
preserve  the  edges  of  the  acetabulum.  The  cavity  must  be  made  not 
only  deep  but  broad.  This  is  best  accomplished  by  cutting  away 
posteriorly. 

The  head  is  now  reduced,  and  goes  into  its  place  with  a  snap. 
The  superfluous  part  of  the  capsule  is  then  extirpated,  the  wound 
partly  sutured,  and  the  rest  packed  with  iodoform  gauze.  If  there  is 
any  rotation  forward  of  the  neck  and  head,  the  limb  must  be  put  up 
in  moderate  inversion,  otherwise  the  head  will  slip  out  of  the  new 
acetabulum.  After  a  few  weeks  it  may  be  brought  to  the  normal 
position.  Lorenz,  in  such  a  case,  also  advises  putting  the  limb  up  in 
inversion,  and  a  subsequent  sub-trochanteric  osteotomy  to  correct  this. 

Careful  passive  movement  is  begun  in  three  or  four  weeks,  and  after 
five  weeks  the  child  is  allowed  to  stand  and  walk  in  an  apparatus 
which  allows  of  motion  of  the  hip,  but  does  not  allow  the  head  to 
escape  from  the  acetabulum. 

It  remains  to  allude  to  the  results  of  operative  interference  both 
good  and  bad,  though  but  little  has  been  heard  of  the  latter.  Redard 
(Traite  de  Chir.  Orthoped.,  Paris.  1892.  p.  534),  Dr.  T.  H.  Myers,  and 
i)r.  V.  P.  Gibney.  of  New  York  (^Ann.  of  Surg.,  Aug.  and  Dec.  1894) 
accept  the  following  conclusions:  "(i)  The  number  of  perfect  cases  is 
very  small.  (2)  The  number  of  cases  improved  is  large.  (3)  The 
results  in  double  dislocation  are  not  so  favourable  as  in  single. 
(4)  The  lordosis  is  generally  corrected.  (5)  The  limp  persists  to  some 
degree,  though  a  high  shoe  will  improve  this  greatly,  A  paper 
by  Dr.  E.  H.  Bradford,  of  Boston,  is  especially  instructive,  as  it 
contains  an  account  of  a  specimen  taken  from  a  child  who  died  of 
diphtheria  and  septicaemia  a  month  after  Hoffa's  operation  had  been 
performed.  He  considers  that  while  "the  method  of  operative  reduction 
offers  the  best  prospect  of  a  cure,  it  involves  risk  and  is  not  certain  in 
its  result." 

Finally  as  to  the  risks.  These  are  certainl_v  serious.  The  following- 
have  been  published: — i.  Shock.  2.  Haemorrhage.  3  and  4.  In  young- 
children  the  effects  of  the  anaesthetic  and  of  iodoform  intoxication  must 
also  be  remembered  together  with  the  above.  5.  Peritonitis.  This 
has  followed  in  one  case,  after  perforation  of  the  bone  in  fashioning  the 
acetabulum.*  6.  Septic  conditions.  7,  Prolonged  suppuration.  Dr. 
Gibney  (loc.  supra  cit.).  with  candour  that  does  him  great  credit,  says 
that  profuse  suppuration  followed  in  the  majority  of  his  nine  cases 
(seven  of  these  were  cases  of  congenital  dislocation).  This  continued 
for  many  weeks  and  months,  during  which  time  the  wound  should  have 
been  healed  and  movements  begun.  8.  Recurrence  of  the  faulty 
position. 

*  A  gouge  and  mallet  were  being  used  (^Rcvue  d?  Orthopedic,  Jan.  1893). 


CHAPTER    III. 
OPERATIONS    ON   THE    THIGH. 

LIGATURE  OP  THE  COMMON  FEMORAL. — LIGATURE  OP 
THE  SUPERPICIAL  FEMORAL  IN  SCARPA'S  TRIANGLE. 
—LIGATURE  OF  THE  SUPERPICIAL  FEMORAL  IN 
HUNTER'S  CANAL.— PUNCTURED  AND  STAB  WOUND  IN 
MID-THIGH. -AMPUTATION  THROUGH  THE  THIGH. — 
AMPUTATION  IMMEDIATELY  ABOVE  THE  KNEE- 
JOINT.—REMOVAL  OF  EXOSTOSIS  FROM  NEAR  THE 
ADDUCTOR  TUBERCLE.  —  UNUNITED  FRACTURE  OP 
THE   FEMUR. 

LIGATURE     OF    THE     COMMON    FEMORAL. 

Though  this  operation  is  not  regarded  with  much  favour,  especially  for 
aneurysm,  it  will  be  described  here,  as  the  question  of  tying  it  arises 
from  time  to  time,  and  as  it  should  always  be  performed,  for  the  sake  of 
practice,  on  the  dead  body. 

Indications. 

I.  Wounds. — These  are  rare,  here,  compared  with  those  affecting  the 
vessels  lower  down.  The  wound  must  always  be  explored  and  the 
bleeding-point  sought,  for  two  reasons — (a)  Ligature  of  the  external 
iliac  will  usually  fail  to  arrest  bleeding  from  the  common  femoral. 
(/>)  The  source  of  the  bleeding  may  easily  be  mistaken  here ;  thus, 
Mr.  Listen,*  in  a  case  of  pistol-shot  wound  of  the  groin,  tied  the 
external  iliac  for  what  was  proved,  post  mortem,  to  be  a  wound  of  "  one 
of  the  superficial  branches  of  the  common  femoral,  about  half  an  inch 
below  Poupart's  ligament." 


*  Mcd.-Chir.  Trans.,  vol.  xxix.  p.  107.  The  flow  of  the  blood  here  is  said  to  have 
been  "  most  impetuous  and  profuse."  In  Mr.  Liston's  words  :  "  The  division  of  even  a 
small  branch  close  to  the  principal  vessel,  it  is  well  known,  pours  out  blood  furiously, 
as  much  so,  in  fact,  as  if  an  opening  in  the  coats  or  the  artery  itself  were,  so  to  say, 
punched  out.  corresponding  in  size  to  the  area  of  the  branch." 


6o8  OPERATIOxXS  OX  THE  LOWER  EXTREMITY. 

After  ligature  for  gunshot  injuries,  whether  for  direct  or  for  conse- 
cutive bleeding  unattended  b}^  primary  injury  to  the  vessel,  the  mor- 
tality in  the  American  War*  seems  to  have  been  high — over  70  per 
cent. 

The  very  important  subject  of  ligature  of  the  femoral  artery  or 
vein,  or  both,  in  cases  of  woimds.  will  be  referred  to  here,  though 
briefly.  Such  cases  will  arise  most  frequently  in  removal  of  growths — 
e.g.,  epitheliomata,  lymphomata,  sarcomata — less  often  in  cases  of  stabs. 
Much  interesting  information  on  these  subjects  will  be  found  in  papers 
by  M.  Kirmisson.f  and  Dr.  L.  Pi]cher.| 

'  2.  Removal  of  Growths  from  Scarpa's  Triangle  and  Injury  to  Femoral 
Vessels. — M.  Kirmisson  has  drawn  attention  to  the  following  points : 
In  the  course  of  the  deeper  dissection  the  pulsation  of  the  femoral 
artery  should  be  frequently  felt  for  with  the  finger.  As  this  vessel  ma^^ 
have  been  displaced,  it  is  not  enough  to  trust  to  anatomical  knowledge 
alone.  After  separating  the  structures  on  either  side  of  the  growth, 
this  should  be  left  adhei'ent  where  it  is  in  connection  with  the  sheath, 
and  especial  care  devoted  to  this  spot.  Where  the  adhesions  are  ver}^ 
firm,  and  where  a  large  growth  surrounds  the  sheath,  it  is  useful  to 
divide  the  growth  and  to  remove  large  pai'ts  of  it,  only  preserving  that 
part  in  intimate  connection  with  the  vessels,  this  being  finally  separated 
most  carefully.  In  the  case  of  gro^^i}hs  in  intimate  connection  with  the 
sheath  the  vein  is  particularly  in  danger,  because  (a)  the  vein-walls  are 
much  more  qiiickly  invaded  than  the  ai'terial,  and  (h)  the  vein  is  in 
closer  connection  with  the  glands.  Two  conditions  are  likely  to  be  met 
with  by  the  surgeon :  i .  Denudation  of  the  vessels.  Here  the  adhe- 
sions are  sufficiently  loose  to  be  separated,  and  the  sheath  is  either  left 
intact  or  opened.  Every  effort  must  be  taken  to  keep  the  wound  here 
aseptic.  2.  Resection  and  ligature  of  one  or  other  of  the  femoral 
vessels.  If  the  vein  alone  has  been  injured  in  an  operation  or  by  a 
stab,  it  should  be  secured  if  possible  by  a  laterally  applied  ligature,  by 
the  application  of  Spencer  Wells's  forceps  left  in  situ  for  two  or  three 
days,  §  or  by  suture  of  the  walls.  All  of  these  formerly  hazardous  pro- 
cedures have  been  rendered  much  safer  by  the  precautions  of  aseptic 
surgery.  Maubrac  (Arch.  Gen.  de  Med.,  1889)  strongly  advocates 
lateral  suture,  especiall}^  when  the  lesion  is  small.  Kammerer  {Neiv 
Yorh  Med.  Journ.,  1890,  vol.  i.  p.  511)  points  out  that  suture  of  the  wall 
has  undoubted  advantages,  and  that  it  has  been  used  successfully  in  the 
case  of  the  femoral  vein  by  Schede  {Arch.  f.  Min.  Chir.,  Bd,  xxviii. 
p.  671),  and  Lange  (New  York  Med.  Jour.,  vol.  xliv.  p.  720).  If  these 
steps    are   impossible,    or   fail,    the   femoral    vein    must   be   ligatured. 

*  Otis  {Medical  and  Sitrr/ical  History  of  the  War  of  the  Rehellion,  part  iii.  pp.  16. 
43,  49)- 

t  Rrr.de  Chir.,  May  10,  1886.  I  am  indebted  for  my  knowledge  of  this  paper  to  an 
abstract  by  Mr.  T.  Jones,  of  Manchester  (Med.  Chron.,  September  1886,  p.  514). 

X  Ann.  of  Surg.,  February  1886. 

§  A  case  in  which  I  thus  treated  a  wound  of  the  internal  jugular  has  been  recorded 
in  Vol.  I.  at  p.  557.  Pilcher  mentions  a  case  of  Kiister's,  in  which  a  wound  in  the  vein 
was  secured  with  h.-emostatic  forceps  ;  the  removal  of  these  after  only  twenty-four 
hours  was  followed  by  renewed  bleeding,  ligature  of  the  femoral  artery,  and  fatal 
gangrene. 


LIGATURE   OF  THE   COMMON  FEMORAL.  609 

Dr.  Pilcher,  quoting  from  a  paper  of  Braun's,*  shows  that  of  eighteen 
cases  in  which  ligature  of  the  femoral  vein  alone  was  practised  at  the 
level  of  Poupart"s  ligament,  thirteen  occurred  as  the  result  of  wounds 
inflicted  during  the  removal  of  growths.  In  none  of  these  thirteen 
cases  did  gangrene  ensue.  Dr.  Pilcher  points  out  that  this  is  due  to  the 
gradual  enlargement  of  the  collateral  venous  circulation  which  takes 
place  during  the  increase  of  the  growth.  This  constitutes  a  most 
important  difference  between  wounds  of  the  vein  during  operation  and 
by  a  stab.  Thus,  in  five  cases  in  which,  as  the  result  of  acute  injuries, 
the  femoral  vein  was  tied  high  up,  recovery  without  disturbance  took 
place  in  only  one.  In  t^o,  death  took  place  from  septicaemia  and 
pygemia  ;  in  the  remaining  two,  gangrene  rapidly  supervened.  In  the 
case  of  stab-wounds  of  the  common  femoral  vessels  the  complication  of 
sepsis  has  to  be  remembered. 

Thus,  Mr.  Gould  (^Med.  Soc.  Proc,  vol.  x.  p.  177)  published  a  case  of  great  interest  in 
which  the  common  femoral  vein  was  wounded  (••  the  whole  anterior  segment  of  the 
vessel  "  being  severed)  with  a  cat's-meat  kuife.  A  ligature  tied  round  the  vein  above 
and  below  the  wound  not  arresting  the  bleeding,  the  internal  saphena  which  entered 
the  femoral  just  opposite  the  wound  was  tied  also.  Blood  still  welled  up  from  the 
wounded  vessel,  and  further  search  showed  that  another  vein  entered  the  femoral 
trunk  just  opposite  the  wound  in  the  trunk  between  the  two  ligatures.  This  vein  was 
tied  and  then  all  hjemorrhage  was  found  to  be  arrested.  Though  the  wound  was  verv 
thoroughly  irrigated  with  solution  of  hydr.  perch.  (1-2000),  all  the  infective  material 
introduced  by  the  knife  could  not  be  removed.  Septic  phlebitis  followed,  with  inflam- 
mation of  the  coats  of  the  artery  and  haemorrhage  on  the  ninth  day  necessitating 
ligature  of  the  superficial  and  deep  femoral  arteries.  Meanwhile  the  septic  thrombus 
had  been  spreading  iip  the  iliac  vein  until  all  the  chief  channels  for  the  return  of 
venous  blood  were  blocked.  This  brought  about  moist  gangrene,  the  patient  dying  on 
the  eleventh  day  with  blood-poisoning,  accelerated  by  the  loss  of  arterial  blood. 

The  question  has  been  raised  whether,  when  ligature  of  the  common 
femoral  vein  has  been  found  needful,  the  common  femoral  artery  should 
not  be  tied  also,  in  order  to  diminish  the  risk  of  gangrene.  Dr.  Pilcher, 
while  quoting  the  cases  of  Roux,  Linhart,  and  Langenbeck,  in  which 
this  step  was  successful,  shows  that  the  practice  of  ligature  of  the 
common  femoral  artery  as  a  prophylactic  step  after  wound  of  the 
common  femoral  vein  high  up,  whether  in  the  removal  of  tumours  or 
injuries — e.(j.,  stabs — is  to  be  discouraged. f 

Dr.  Pilcher  suggests  {loc.  mpra  cit.,  p.  119)  that  where  the  femoral 
vein  has  been  suddenly  and  completely  occluded  high  up  it  will  be  wiser 
to  tie  not  the  common  but  the  superficial  femoral  artery,  as  likely  to 
materially  diminish  the  current  to  the  limb,  while  the  amount  provided 
will  be  quite  sufficient  for  its  nutrition. 

In  cases  where  both  vein  and  artery  are  wounded  these  must  be 
secured  in  situ.  The  risk  of  gangrene  is  now  enormously  increased, 
though  the  risk  will  vary  somewhat  according  as  the  simultaneoiis 
ligature  is  made  above  or  below  the  deep  femoral. 

A  few  other  points  bearing  upon  the  removal  of  tumours  here  may  be 
alluded  to.     The  internal  saphena  vein  should  be  carefully  preserved 

*  Arch.f.  klin.  Chir.,  Bd.  xxviii.  Heft.  3,  S.  610. 

t  la  support  of  this,  Dr.  Pilcher  writes  :  "  To  diminish,  to  an  extreme  degree,  the 
.arterial  supply  to  a  part  whose  nutrition  is  already  seriously  compromised  by  general 
venous  stasis,  would  certainly  tend  to  precipitate  and  aggravate  tlie  threatened 
uecrosis." 

VOL.   II.  39 


6 10  OPERATIOXS  OX   THE  LOWER  EXTREMITY. 

intact,  and  where  it  is  really  needful  to  divide  it  this  should  be  done  as 
far  from  the  main  femoral  trunk  as  possible,  otherwise  most  trouble- 
some oedema  may  subsequently  develop.  * 

In  operating  close  to  Poupart's  ligament,  and  especially  on  the  inner 
side,  the  presence  of  the  peritoneum, f  and  the  possible  existence  of  a 
femoral  hernia,  must  be  remembered. 

3.  Ulceration  into  the  Arter}-  b}-  Growths. — From  the  frequency  of 
gro^A'ths  here  this  indication  will  occasionally  arise.  I  have  met  ^^■ith 
one  case.  A  man  was  admitted  under  my  care  who  had  been  operated 
on  elsewhere  for  the  removal  of  sarcomatous  glands  in  the  groin.  The 
application  of  zinc  chloride  paste  had  led  to  detachment  of  sloughs  and 
exposure  of  the  common  femoral,  which  gave  way,  leading  to  profuse 
htemorrhage.  I  tied  the  common  femoral  immediately  above  the 
bleeding-point ;  this  was  slowly  followed  by  typical'  dry  gangrene, 
necessitating  amputation  through  the  lower  third  of  the  thigh. 

4.  Ulceration  into  Femoral  Vessels  in  Inguinal  Bubo. — Mr.  Shield 
has  drawn  attention  to  this  most  dangerous  condition  (Med.  Soc.  Proc, 
vol.  X.  p  261).  Though  in  his  case  ulceration  occurred  in  the  superficial 
femoral  vessels,  I  have  alluded  to  it  here,  in  association  with  the  previous 
two  headings.  Owing  to  haemorrhage  from  sloughing  sinuses  in 
Scarpa's  triangle,  Mr.  Shield  was  obliged  to  tie  both  artery  and  vein, 
using  two  ligatures  in  each  case.  There  was  no  return  of  hfemorrhage, 
and  gangrene  did  not  occur,  but  the  patient  sank  exhausted  on  the 
eleventh  da}^  with  a  large  pytemic  abscess  in  the  opposite  hip-joint. 
Mr.  Shield  points  out  that  in  these  most  dangerous  cases  of  spreading 
sloughing  bubo,  preventive  treatment — use  of  the  sharp-spoon,  chloride 
of  zinc  paste,  continuous  warm  baths,  &c. — is  urgently  indicated.  When 
ouce  bleeding  has  occurred  and  recurred,  as  jiressurcJ:  owing  to  the 
condition  of  the  soft  parts,  is  likely  to  fail,  a  free  incision  and  ligature 
of  the  vessels  above  and  below  the  point  of  ulceration  is  the  wisest 
course. 

5.  Aneurysm. — There  has  been  much  difference  of  opinion  as  to 
whether  it  is  wiser,  when  dealing  Avith  an  aneurysm  on  the  superficial 
femoral  high  up.  to  tie  the  common  femoral  or  the  external  iliac. 
PiUglish  surgeons  have  rejected  ligature  of  the  common  femoral  for 
these  reasons — (i)  The  risk  of  gangrene,  as  the  ligature  is  placed  above 
both  the  great  nutrient  arteries  of  the  limb.  (2)  The  probability  of  firm 
clotting  taking  place  after  the  ligature  is  rendered  doubtful,  owing  to 
the  number  of  small  vessels  given  off  here — viz.,  the  superficial  epi- 
gastric, and  circumflex  iliac,  the  superior  and  inferior  external  puclic, 
and  verv  commonlv  one  of   the  circumflex   arteries,  and   also  bv  the 


*  Dr.  Pilcher  (Joe.  infra  cit..  p.  214)  mentions  a  case  vrhere,  after  ligature  of  the 
saphena  vein  close  to  the  common  femoral,  the  tendency  to  ceclema  was  so  great  that  the 
patient,  unfitted  for  work,  begged  for  removal  of  the  limb. 

f  M.  Kirmisson  gives  a  case  in  which  the  peritonteuni  was  wounded  and  sutured,  the 
patient  recovering. 

%  At  the  debate  on  Mr.  Shield's  paper.  Mr.  Cripps — a  high  authority — supported 
pressure  in  fhoso.  cases.  It  should  be  applied  methodically  according  to  Mr.  Cripps's 
plan  (vide  infra,  p.  617),  and,  to  secure  asepsis  in  these  most  persistently  foul  cases,  it 
would  be  well  to  try  the  application  of  that  powerful  styptic  and  disinfectant, 
turpentine. 


LIGATL'RE   OF  THE  COMMON  FEMORAL.  6ll 

proximity  of  the  profunda.  (3)  The  uncertainty  of  the  origin  of  the 
profunda,  and  thus  of  the  length  of  the  common  femoral.  (4)  I  would 
add  to  the  above  that  ligature  of  the  common  femoral  for  aneurysm 
approximates  the  treatment  to  that  of  Anel  i-ather  than  to  that  of 
Hunter.  Sir  J.  E.  Erichsen *  went  so  far  as  to  say,  "It  may  be  laid 
down  as  a  rule  in  surgery,  that  in  all  those  cases  of  aneurysm  which  are 
situated  above  the  middle  of  the  thigh,  in  which  compression  has  failed 
and  sufficient  space  does  not  intervene  between  the  origin  of  the  deep 
femoral  and  the  upper  part  of  the  sac  for  the  application  of  a  ligature  to 
the  superficial  femoral,  the  external  iliac  should  be  tied." 

Mr.  Holmes, t  while  adducing  facts  to  show  that  the  operation  on  the 
common  femoral  is  not  in  itself  by  any  means  so  fatal  as  has  been  repre- 
sented, and  that  no  just  cause  whatever  has  been  shown  for  banishing  it 
from  surgical  practice,  allows  that  he  should  be  in  favour  of  ligature  of 
the  external  iliac  for  femoral  aneurysm  higli  up,  under  ordinary  circum- 
stances, reserving  ligature  of  the  common  femoral  for  cases  where  the 
belly  is  extremeh'  fat. 

The  opposite  opinion  has  been  held  by  some  of  the  Irish  surgeons — 
viz.,  the  two  Porters,  Mr.  Smyly,  Mr.  Butcher,  and  Dr.  Macnamara. 
The  last-mentioned  surgeon  has  published  ±  eight  cases,  of  which  six 
were  successful,  two  dying  of  hasmorrhage. 

It  is  probable,  however,  that,  for  the  reasons  given  above,  ligature  of 
the  external  iliac  will  be  preferred,  especially  as,  nowadays,  antiseptic 
precaiitions  and  improved  ligatures  will  have  rendered  this  opei^ation 
increasingly  safe. 

6.  As  a  Preparatory  Step  to  Amputation  at  the  Hip-joint. — Tlie  need 
of  this  has  been  largely  done  away  with  by  the  Furneaux  Jordan  method. 
Where  this  is  not  available,  one  of  the  other  means  given  at  p.  579. 
will,  I  think,  be  found  preferable. 

Line  and  Guide. — From  a  point  midway  between  the  anterior  superior 
spine  of  the  ilium  and  symphysis  pubis  to  the  adductor  tubercle,  and 
the  inner  margin  of  the  internal  condyle. 

Another  line  is  sometimes  taken  from  the  centre  of  Poupart's  liga- 
ment (or  a  point  midway  between  the  two  spines)  to  the  inner  margin 
of  the  patella  or  the  front  of  the  internal  condyle,  but  that  above  given 
is  the  more  correct. 

Relations:  In  Front. 

Skin  ;  fascise  ;  lymphatic  glands. 
Crural  branch  of  genito-crural.     Sheath. 
Outside.  Inside. 

Anterior  crural.  Common  femoral.  Septum  of  sheath. 

Femoral  vein. 
Behind. 
Sheath. 
Psoas. 

It  is  important  to  note  that  the  common  femoral  is  usually  only  an 
inch  and  a  half  long,  and  that  from  it  come  oif  not  only  the  superficial 

*  Surgery,  vol.  ii.  p.  244.  f  Hunt.  Lect.,  Lancet,  1874,  vol.  ii.  p.  300. 

%  Brit.  Med.  Journ.,  October,  5,  1867,  Mr.  G.  H.  Porter  (^Dub.  Journ.  Med.  Sci.,  vol. 
XXX.  N.S.  i860,  p.  302)  reports  three  cases,  and  alludes  to  two  under  his  father's  care. 
All  were  successful,  though  secondary  hsemorrhage  occurred  in  two. 


6l2  OPERATIONS   ON  THE  LOWER  EXTREMITY. 

epigastric,  circumflex  iliac,  and  superior  and  inferior  external  pudic, 
but  occasionally  one  of  the  circumflex  arteries  as  well. 

Collateral  Circulation. 

Above.  Below. 

Glutasal  and  sciatic,  with         Superior  perforating  and  cir- 

cumflex arteries. 

Superficial  circumflex  iliac,  with         Ascending  branch  of  exter- 

nal circumflex. 

Obturator,  with         Internal  circumflex. 

Comes  nervi  ischiadici,  with         Perforating  of  profunda  and 

articular  of  popliteal. 

Operation. — The  groin  having  been  shaved  and  cleansed,  the  hip  and 
knee  semiflexed,  and  the  limb  abducted  and  rotated  some^^■hat  outwards, 
an  incision  about  two  and  a  half  inches  long  is  made  in  the  line  of  the 
artery,  commencing  just  above  Poupart's  ligament.  The  skin  and 
superficial  fascia  having  been  divided,  and  any  overlying  glands  dis- 
placed or  removed,  anj"  veins  which  may  be  met  with  descending  to  join 
the  internal  saphena  are  either  drawn  aside  or  tied  between  double 
ligatures.  The  fascia  lata  having  been  opened  just  below  Poupart's 
ligament,  the  artery  or  its  pulsation  is  felt  for,  the  vessel  exposed  here, 
and  the  needle  passed  from  within  outwards,  care  being  taken  to  avoid 
the  crural  branch  of  the  genito-crural  nerve,  Avhich  lies  superficial  to  the 
artery.  The  neighbourhood  of  any  branch  is,  if  possible,  avoided.  The 
Avound  is  then  most  carefully  dried  out  and  closed. 

By  another  method  the  artery  is  found  b}'  an  incision  parallel  with 
the  centre  of  Poupart's  ligament  and  about  half  an  inch  below  it.  This 
is  recommended  b}-  Mr.  Porter  and  Dr.  Macnamara  (loc.  supra  cit.).  Of 
the  two,  the  first,  in  the  line  of  the  vessel,  is  to  be  preferred. 

LIGATURE   OF  THE  SUPERFICIAL  FEMORAL  IN 
SCARPA'S  TRIANGLE  (Figs.  239  and  240). 

Indications. 

1 .  Certain  Cases  of  Aneurysm  of  the  Popliteal  Artery  or  the  Femoral 
low  down. — Thus  the  ligature  will  probably  be  indicated — (a)  where  a 
popliteal  aneurysm  is  rapidly  growing,  especially  when  (h)  it  is  on  the 
anterior  aspect  of  the  artery  instead  of  behind  or  at  one  side  of  it,  as  in 
the  former  case  the  knee-joint  may  become  involved  after  very  obscure 
symptoms  ;  (c)  when  the  aneurysm  is  fusiform  rather  than  saccular ;  (d) 
when  it  has  very  thin  walls ;  (e)  when  it  threatens  to  burst,  or  when 
this  has  already  happened,  unless  other  sjanptoms — e.g.,  gangrene — call 
for  amputation  ;  ( /")  if  visceral  disease — cardiac,  renal,  hepatic — or  an 
atheromatous  condition  of  the  vessels  is  present,  the  surgeon  must  weigh 
carefully  the  question  of  operative  interference  :  I  should  prefer  in  most 
cases  a  trial  of  the  ligature  as  likel}^  with  the  aid  of  antiseptic  pre- 
cautions, a  modern  ligature  and  primarj^  union,  to  entail  less  taxing  of 
the  patient's  powers  ;  (7)  where  a  trial  of  pressure  has  failed,  or  is  certain 
to  fail  from  the  irritability  of  the  patient. 

2.  Wounds. — Nothing  need  be  added  here  to  what  is  said  on  the 
subject  at  pp.  607  and  616. 


k 


LIGATUEE  OF  FE3I0RAL  IN  SCARPA'S  TRIANGLE.  613 

3.  For  Haemorrhage  low  down — e.g.,  after  amputation  in  the  middle 
of  the  thigh,  when  other  means  fail  and  the  wound  is  nearly  united 
(p.  618).  Two  other  instances  are  given  by  Mr.  Bryant  {Surgeri/, 
vol.  ii.  p.  417).  One  was  "  a  case  of  Mr.  Bransby  Coopers  in  which  a 
compound  fracture  of  the  leg  was  complicated  with  a  laceration  of  the 
femoral  artery.  The  artery  was  secured  at  the  seat  of  injury,  and  repair 
went  on  well  in  all  respects.  Mr.  Bransby  Cooper  has  also  recorded  in 
his  Surgical  Essaijs  a  case  of  fracture  of  the  femur  in  which  the  femoral 
artery  was  ligatured  for  a  ruptured  popliteal  arter}-,  and  in  which  re- 
covery took  place  in  six  weeks."  Each  of  such  cases  must  be  considered 
on  its  own  merits,  but  the  above  shows  what  ligature  of  the  femoral 
artery  will  do  in  appropriate  cases. 

4.  For  Elephantiasis. — Cases  in  which  the  superficial  femoral  has  been 
tied  will  be  found  in  the  Lancet  for  1 879,  vol.  i.  p.  44 ;  and  Ranking's 
Ahstrad  for  i860,  vol.  ii.  p.  193.  The  subject  of  ligature  of  the  main 
artery  of  a  limb  for  this  affection  has  been  considered  at  p.   3. 

5.  Acute  Inflammation  of  the  Knee-joint. — Mr.  Maunder  brought  a 
case  before  the  Clinical  Society  {Trans.,  vol.  ii.  p.  2)7),  in  which,  at  his 
suggestion,  Mr.  Little  had  tied  the  femoral  artery  for  acute  inflammation 
of  the  knee-joint,  ten  days  after  a  lacerated  wound.  The  pain  and  other 
acute  symptoms  were  at  once  relieved,  and  the  patient  made  a  good 
recovery.  The  antiseptic  treatment  of  wounds  of  joints,  aided  by  free 
incisions,  will,  nowadays,  do  away  with  the  need  of  the  above  treatment. 

Line. — That  above  given,  p.  61 1. 

Guide. — The  above  line  and  the  inner  border  of  the  sartorius  at  the 
apex  of  the  triangle. 
Relations. — 

In  Front. 
Skin  ;  superficial  fascia  ;  glands  ;  crural 
branch  of  genito-crural  nerve ;  middle 
cutaneous  and  branch  of  internal  cu- 
taneous ;  fascia  lata ;  sartorius. 
Outside.  Inside. 

Femoral  vein  (below).     Ante-  Femoral  vein  (above), 

rior  crural  nerve,  and  some 
of  its  branches — viz.,  the 
nerve  to  the  vastus  internus, 
and  long  saphenous  nerve. 

Behind. 
Psoas  ;  pectineus  ;   adductor  longus  ;  fe- 
moral vein  (below) ;  profunda    artery 
and  vein ;  nerves  to  pectineus. 
Collateral  Circulation. 

Above.  Below. 

Perforating  of  profunda,          with       Lower  muscular  and  anastomotic 

of  femoral,  articular  of  popli- 
teal, and  anterior  tibial  recur- 
rent. 
External    circumflex    of 

profunda,  with       Ditto  ditto. 

Comes    nervi    ischiadici,         with       Perforating    of    profunda     and 

articular  of  popliteal. 


6i4 


OPERATIONS  OX  THE  LOWER  EXTREMITY. 


Operation. — (Figs,  239,  240). — The  parts  having  been  shaved  and 
cleansed,  the  knee  and  hip  slightly  flexed,  the  thigh  abducted  and  some- 
what everted,  and  the  leg  resting  on  a  pillow,  the  surgeon,  seated  or 


Fig.  238. 
Ilio-lumbar  branch  of  iuternal  iliac. 


Deep  circumflex  iliac 


Profunda 

External  circumflex 


Superior   oxternal    arti- 
cular   

Inferior   external    arti- 
cular   

Posteriortibial  recurrent 

Ante-ior     tibial     recur 

rent 

Superior  fibular 


Common  iliac. 


Internal  iliac. 
Deep  epigastric. 

External  iliac. 
Obturator. 

Common  femoral. 
Sciatic. 

Internal  pudic. 

Internal  circumflex. 

Superficial  femoral. 


-  PpiforatinK   brandies  of 
j>rofunda 


Anastomotica  magna. 
Popliteal. 


Superior  muscular 
blanches  of  popliteal. 


Superior    internal    arti- 
cular. 


Inferior    internal     arti- 
cular. 
Posterior  tibial. 


.Ynterior  tibial. 


Anastomotic  circulation  of  the  iliac  and  femoral  arteries.     (Mac  Cormac.) 


LIGATURE  OF  FEMORAL  IX  SCARPA'S  TRIANGLE. 


615 


Fig 


k 


standing  to  the  right  of  the  affected  limb,  makes  an  incision  three  inches 
long  in  the  line  of  the  artery  (p.  611).  This  should  begin  about  two 
inches  and  a  half  below  Poupart's  ligament,  and  run  down  to,  and  some- 
what below,  the  apex  of  Scarpa's  triangle,  which  lies  usually  four  to  five 
inches  below  Poupart's  ligament.  The  skin  and  superficial  fascia  liaving 
been  divided,  anj'  small  vessels  are  secured,  and  branches  of  the  saphena 
vein  drawn  aside  with  a  strabismus 
hook  or  secured  with  double  liga- 
tures. The  deep  fascia  is  now  slit 
up  for  the  whole  length  of  the  wound, 
and  the  inner  margin  of  the  sar- 
torius,  which  crosses  the  lower  part 
of  the  incision,  identified.  This  is 
then  drawn  outwards,  and  so  held 
with  a  blunt  hook  or  retractor,  while 
the  artery  or  its  pulsation  is  felt  for. 
The  wound  being  now  well  opened 
out  with  retractors  and  carefully 
wiped  out,  the  sheath  is  opened  to 
the  outer  side,  care  being  taken  to 
a,void  the  nerves  in  contact  with  it 
— viz.,  the  long  saphenous,  and 
the  nerve  to  the  vastus  internus. 
The  artery  having  been  cleaned, 
thoroughh'  but  most  carefully,  on 
either  side  and  behind,  the  needle 
is  passed  from  Avithin  outwards, 
being  kept  very  close  to  the  vessel 
so  as  to  avoid  the  vein  A\hich  lies 
behind  and  internally.*  The  artery 
having  been  tied,  the  ligature  is  cut 
short,  drainage  provided  hj  horse- 
hair or  a  small  tube,  according  to 
the  amount  of  disturbance  of  the 
parts,  &c.  and  the  wound  closed, 
for  the  prevention  of  gangrene  must  be  taken. 

DiflB-Culties  and  Mistakes. 

I.  Wounding  the  Saphena  Vein. — This  may  occur  if  the  incision  is 
made  too  internal.  It  is  always  to  be  avoided  if  possible,  owing  to  the 
troublesome  oedema  A\-hich  may  follow.  2.  A  very  broad  Sartorius. 
3.  Injury  to  the  Femoral  A'ein. — This  may  easily  take  place  if  force  is 
used  in  pushing  the  needle  roand  an  imperfectly  cleaned  arfcer}',  or  if 

*  The  vein  is  so  frequently  damaged  here,  especially  on  the  dead  subject,  that  a  few- 
precautions  may  be  given  as  to  the  best  way  of  avoiding  it.  First,  the  sheath  must 
be  identified  exactly,  and  sufficiently  opened  at  its  outer  part.  It  will  be  found  of 
much  help  in  cleaning  the  vessel  if  one  edge  of  the  cut  sheath  is  held  by  an  assistant , 
while  the  surgeon  has  hold  of  the  other  ;  the  opening  in  the  sheath  is  thus  made  sure 
of  and  retained.  There  must  be  no  needless  disturbance,  or  lifting  up  of  the  vessel 
upon  the  needle,  which,  with  the  director,  must  be  used  with  the  utmost  carefulness. 
As  soon  as  the  eye  (and  this  should  be  at  the  very  end  of  the  needle)  is  seen  to  have 
passed  round  the  vessel  the  ligature  should  be  at  once  seized  and  the  needle 
withdrawn. 


Ligature  of  the  common  femoral,  aud  the 
superficial  femoral  at  the  apex  of  Scarpa's 
triangle.  The  ligature  in  each  case  has  been 
passed  from  within  outwards.     (Sedillot.) 

The    precautions    given   at    p.    6 


6i6 


OPERATIONS  ON  THE  LOWER  EXTREMITY. 


the  needle  is  not  kept  close  to  the  vessel.     If  the  accident  occur,  the 
surgeon  must  not  persist  in  his  attempt  to  tie  the  artery  at  this  spot,  a 

course  which  will  only  end 
240. 


Fig-  240.  in  his  inflicting  more  injury 

in  the  vein,  but  finger^ 
pressure  being  made  in  the 
lower  angle  of  the  wound, 
the  artery  is  tied  either 
above  or  below  the  spot 
where  the  vein  has  been 
injured.  As  soon  as  the 
artery  is  secui'ed,  no  fur- 
ther haemorrhage  will  take 
place,  but  pressure  may  be 
kept  up  by  means  of  steri- 
lised dressings  over  the 
wound  for  a  day  or  two.* 
The  patient  will  do  well  to 
wear  a  Martin's  bandage 
or  an  elastic  stocking  for 
some  time  after  getting  up. 
4.  Including  one  of  the 
nerves.  5.  A  matted  con- 
dition of  the  parts  due 
to  a  i^revious  trial  of 
compression. 

Abnormalities     of     the 
Femoral  Artery. 

I.  A  double  superficial 
femoral,  the  two  trunks 
uniting  below  to  form  the 
popliteal.  More  than  one 
case  of  this  kind  is  recorded.  The  persistence  of  pulsation  in  the 
aneurysm  after  the  first  ligature  would  lead  to  a  suspicion  of  this 
condition.     2.  The  vessel  may  run  down  at  the  back  of  the  limb. 


Dissection  of  parts  concerned  in  ligature  of  the 
femoral  artery  at  the  apex  of  Scarpa's  triangle. 
I.  Fasciae.  2.  Sartorius.  3  and  4.  Superficial  femoral 
artei-y  and  vein. 


LIGATURE  OP  THE 
CANAL  (Fig.  242). 
THIGH  (Fig.  241). 


FEMORAL     ARTERY     IN     HUNTER'S 
-TREATMENT    OF    A    STAB    IN    MID- 


Indications  for  Ligature  of  the  Femoral  Artery  in  Hunter's 
Canal. 

I.  Wounds. — These  may  be,  (a)  incised  ;   (//)  punctured. 

(a)  Here,  if  immediate  death  from  haemorrhage  has  been  prevented, 
the  wounded  vessel  must  be  secured.  The  arterj^  above  being  com- 
pressed by  an  Esmarch's  bandage  or  the  hands  of  an  assistant,  the 
wound  is  enlarged,  clots  are  sponged  away,  and  the  artery  tied  above 
and   below    the    wound  in  it  (Fig.  241).     If   the  vein  is  injured  too 


*  If  venous  hasmorrhage  persist,  the  opening  in  the  vessel  should  be  secured  with 
a  chromic-gut  ligature,  or  a  pair  of  Spencer  Wells's  forceps  left  in  situ  (p.  608). 


LIGATURE  OF  FEMORAL  IX  HUNTER'S  CANAL. 


617 


^ 


Fig.  241. 


^,-- 


/ 


severely  for  a  laterally  applied  ligature  (p.  608),  and  requires  ligature 
in  the  ordinary  way,  the  patient  or  the  friends  must  be  prepared  for 
the  imminent  need  of  amputation. 

(b)  If  a  punctured  wound  lies  in  the  line  of  the  artery  (p.  613),  and 
if  much  blood  has  been  lost,  the 
main  trunk  is  probably  injured,  and 
the  question  will  arise,  if  the  bleed- 
ing has  ceased,  whether  to  cut  down 
upon  the  artery  or  to  trust  to  pres- 
sure. ]\Ir.  Cripps  (Did.  of  Sur<j., 
vol.  i.  p.  525)  advises  that,  if  the 
wound  be  in  the  upper  part  of  the 
thigh,  "the  surgeon  may  enlarge 
the  wound  with  a  good  prospect  of 
finding  the  wounded  vessel  without 
an  extensive  or  prolonged  operation. 
If  the  wound  be  in  the  lower  halt 
of  the  thigh,  owing  to  the  greater 
depth  of  the  artery  and  the  possi- 
bility of  its  being  the  popliteal  which 
is  wounded,  the  search  is  rendered 
far  more  severe  and  hazardous,  and 
it  should  not  be  taken  until  a 
thorough  trial  of  pressure  has  proved 
ineffectual." 

The  following  mode  of  applying 
pressure  is  taken  from  Mr.  Cripps 
(loc.  siqrra  cit.)f'  I  would  also  refer 
my  readers  to  the  account  of  punc- 
tured wound  of  the  palm  given  at 
p.  26,  Vol.  I.,  of  this  work. 

The  main  vessel  having  been  con- 
trolled above,  the  foot  and  leg 
should  be  carefully  strapped  from 
the  toes  to  the  knee,  and  a  bandage 
then  carried  from  the  toes  up  to  the 
wound,  and  then,  avoiding  this,  up 
to  the  groin,  where  it  is  secured, 
spica-fashion,  over  a  pad  on  the  main 

artery.  The  limb  is  then  laid  on  a  long  back  splint  with  a  foot-piece, 
and  secured  to  this  in  an  elevated  position.  The  wound  having  been 
cleansed  and  dusted  with  iodoform,  a  graduated  compress  is  then 
fastened  over  it.  Two  rectal  bougies  are  then  applied  in  the  course  of 
the  artery,  above  and  below  the  wound,  outside  the  bandage  which 
surrounds  the  limb,  so  as  to  keep  these  segments  of  vessel  empty.    Two 


Incised  wound  of  the  thigh  explored  and 
found  to  involve  the  femoral  artery.  An 
Esmarch's  bandage  should  have  been 
shown  ill  situ  above. 


*  Mr.  Cripps's  account  will  be  found  under  the  heading  of  the  treatment  of 
secondary  haemorrhage  from  the  femoral.  He  draws  attention  to  the  instructiveness 
of  the  literature  of  this  subject,  as  it  proves  not  only  that  many  cases  have  been 
successfully  treated  by  pressure  from  the  first,  but  that  both  life  and  limb  have  been 
saved  by  pressure  after  the  surgeon  has  failed  to  find  the  artery  in  the  wound,  or 
after  the  iliac  has  been  tied  in  vain. 


6i8 


OPEEATIOXS  OX  TPIE  LOWER  EXTREMITY. 


well-padded  lateral  splints  are  then  secured  with  straps  and  buckles  to 
the  thigh.     Morphia  must  be  given  as  freely  as  is  judicious.* 

2.  Haemorrhage  from  a  Stump  after  Amputation  in  the  Lower  Third 
of  Thigh  or  Knee. — If  clearing  aA^'ay  the  clots  and  disinfecting  the 
stump,  followed  by  well-adjusted  pi*essure,  and,  this  failing,  tiying  to 
find  the  bleeding  point  in  the  flaps,  do  not  suffice,  the  artery-  must  be 
tied  above. t 

Line  and  Guide  (p,  6ii). 
Relations  : 

In  Front. 
Saphena  vein. 

Skin  ;    fascite ;    sartorius  ;    aponeurosis  between 
vastus  internus  and  adductors. 

Outside.  Inside. 

Vastus  internus  ;  vein  (slightly).  Adductor  longus  and  magnus. 

Femoral  artery  in  Hunter's  canal. 

Behind. 

Femoral  vein  (especially  above). 

Operation  (Fig.  242). — The  knee  and  hip  having  been  flexed,  and  the 
limb  abducted  and  rotated  outwards,  the  surgeon,  seated  comfortabl}'  on 

Fig.   242. 


Ligature  of  the  femoral  artery  in  Hunter's  canal.  The  sui-geon  standing  out- 
side finds  the  furrow  between  the  adductors  and  the  quadriceps,  and  then  makes 
an  incision  in  the  line  given  at  p.  6ii.  The  lower  lip  of  the  wound  having 
been  depressed  with  the  left  thumb,  the  deep  fascia  is  divided  on  a  director. 
(Farabeuf). 


*  Mr.  Cripps  advises  that  the  limb  should  be  slightly  raised  on  a  pillow,  and  partly 
bent  at  the  knee  and  thigh.  The  toes  should  be  left  exposed  that  their  condition 
may  be  watched. 

t  I  would  again  refer  my  readers  to  Mr.  Cripps's  article  Qoc.  svpra  cit.,  p.  526).  He 
points  out  that  a  decision  between  opening  the  flaps  or  ligaturing  the  main  vessel  high 
up  must  depend  on  the  amount  of  union,  and  that  if  the  flaps  must  be  opened  and 
the  vessel  sought  for  before  there  is  much  firm  union,  as  in  the  first  fortnight,  a 
director  should  be  used  rather  than  a  knife,  and  that  if  the  vessel  is  found,  its  soft 
condition  will  require  very  gentle  tying. 


1 


AMPUTATION  THROUGH  THE  THIGH.  619 

the  inner  side  of  the  limb,  makes  an  incision  three  inches  and  a  half 
long  in  the  line  of  the  artery  in  the  middle  third  of  the  thigh.* 
The  skin,  superficial  and  deep  fasciae,  having  been  divided,  and  the 
saphena  vein  drawn  to  one  side  with  a  strabismus  hook,  and  any  of  its 
branches  divided  between  double  ligatures,  the  sartorius  is  identified  by 
the  direction  of  its  fibres  and  drawn  to  the  inner  side.  The  canal  is 
next  opened  by  dividing  the  aponeurotic  roof,  and  the  artery  or  its 
pulsation  felt  for.  The  vessel  will  be  found  closely  connected  to  its 
vein,  which  lies  behind  it,  while  the  saphenous  nerve  crosses  it  from 
without  in^\'ards.  The  artery  having  been  most  carefully  cleaned  all 
round,  the  ligature  ma}'  be  passed  from  either  side,  as  is  found  most 
convenient. t 

Causes  of  Failure  after  Ligature  of  the  Femoral. 

I.  Gangrene.  2.  Secondary  Htemorrhage. — If  pressure  fail,  an 
attempt  must  be  made  to  re-tie  the  vessel,  and,  this  not  succeeding, 
the  limb  must  be  amputated.  3.  Suppuration  of  the  Sac  of  an 
Aneurysm. — This  is  ver}-  rare.  4.  Kecurrent  Pulsation  in  the 
Aneurysm. — The  premature  softening  of  the  ligature,  especially  in  a 
septic  wound,  must  always  be  remembered  as  a  possible  cause  of  this. 
Pressure  failing,  the  artery  may  be  tied  lower  down.  5.  A  very  rare 
complication  is  the  formation  of  an  aneurysm  at  the  seat  of  ligature. 


AMPUTATION  THROUGH  THE  THIGH   (Figs.  243-246). 

Practical  Points  in  Amputation  of  the  Thigh. — As  the  soft  parts 
behind  are  more  bulky  than  those  in  front,  and  as  it  is  desirable  to 
place  the  bone  as  near  as  possible  in  the  centre  of  the  soft  parts,  the 
back  of  the  thigh,  in  the  case  of  a  bulky  limb,  may  be  supported  by  the 
hand  of  an  assistant  during  the  first  introduction  of  the  knife  to  form 
the  anterior  tlaj)  (Skey).  Amputation  should  always  be  performed  as 
low  down  as. possible,  not  only  to  avoid  shock  and  to  secure  as  long  a 
stump  as  possible  for  the  artificial  limb,  but  also  to  secure  as  much  as 
possible  of  the  rectus  femoris.  This  muscle  is  a  most  important  agent 
by  A\hich  the  thigh  is  put  forward  in  stepping.  Its  division  does  not 
preclude  the  retention  of  its  office,  as  it  acquires  a  sufficient  adhesion  to 
the  material  of  the  stump  to  answer  every  useful  purpose,  as  an  agent 
in  the  flexion  of  the  thigh  on  the  pelvis,  though  that  of  extension  of 
the  leg  be  destroj-ed  (Skey,  Oj^er.  Sicni..  p.  391  J. 

*  This  incision  must  not  Le  made  too  lu\v  down.  Its  centre  should  correspond  to 
the  centre  of  the  thigh. 

t  Much  difficulty  will  be  met  with  in  tying  the  femoral  artery  in  Hunter's  canal 
unless  the  line  of  the  artery  (p.  611)  is  strictly  followed.  A  common  mistake  is  to 
make  the  incision  too  far  out,  thus  exposing  the  fibres  of  the  vastus  internus.  which 
run  downwards  and  outwards,  instead  of  those  of  the  sartorius,  which  run  downwards 
and  inwards  (Smith  and  AValsham,  3Iau.  of  Opcr.  Surr/.,  p.  83).  Sir  J.  E.  Erichsen 
{Si/ri/crt/,  vol.  ii.  p.  250),  who  gives  as  the  line  of  the  artery,  one  drawn  from  a  point 
<;xactly  midway  between  the  anterior  superior  spine  and  the  symphysis  pubis  to  the 
most  prominent  part  of  the  internal  condyle,  insists  on  the  need  of  making  the 
incision  a  finger's-breadth  internal  to  this.  The  line  which  I  have  given  above  will 
be  found  sufficientlv  internal. 


620 


OPERATIONS  OX  THE  LOWER  EXTREMITY. 


Different  Methods. — The  following  five,  which  will  give  ample 
choice,  will  alone  be  described  here;  the  first  is  especially  recom- 
mended : 

I.  Mixed  Antero-posterior  Flaps  and  Circular  Division  of  the 
Muscles.  II.  Antero-posterior  Flaps  by  Transfixion.  III.  The 
Circular  Method.     IV.     Rectangular  Flaps.    A  .     Lateral  Flaps. 

I.  Mixed  Antero-posterior  Flaps  and  Circular  Division  of  the 
Muscles  (Fig.  243). — By  the  term  mixed  is  meant  an  anterior  flap  of 
skin  and  fascias  raised  from  without,  and  a  posterior  one  made  by 
transfixion.  The  anterior  is,  wherever  practicable,  made  the  longer  of 
the  two. 

This  method  has  the  following  great  advantages:  (i)  Tlie  longer 
anterior  flap  falls  well  over  the  bone,  and  thus  keeps  the  scar  behind  ; 
(2)  being  raised  from  without  inwards,  it  can  be  taken  from  the 
neighbourhood  of  the  knee-joint  and  patella ;  (3)  it  is  a  most  ex- 
peditious method.*  almost  as  quick  as  that  by  double  transfixion  flaps  ;. 

Fig.  243. 


The  knife  should  have  been  inserted  here  from  the  inner  side. 

(4)  it  is  suited  to  all  cases,  save  perhaps  those  of  very  muscular  thighs,, 
where  the  surgeon  should  be  careful  to  take  only  part  of  the  muscles- 
.behind  as  he  transfixes,  or  else  should  raise  his  posterior  flap  also  from 
without  inwards  :  (5)  it  gives  good  drainage. 

Operation. — The  femoral  artery  having  been  controlled  with  an 
Esmarch's  bandage. f  the  limb  being  brought  over  the  edge  of  the- 
table,  and  supported  by  an  assistant,  who  has  bandaged  the  damaged 
or  diseased  part  to  give  his  hands  a  firmer  grip,  and  to  prevent  their 
becoming  septic;  the  opposite  ankle  being  tied  to  the  table,  and  the 
parts  duly  cleansed,  the  surgeon  standing  to  the  right  side  of  the  limb' 
to  be  removed,  places  his  left  index  and  thumb  on  either  side  of  the 
limb,  at  the  level  where  he  intends  to  saw  the  bone,:|:  and  sinking  the 
point  of  his  knife  through  the  skin  just  below  the  former  and  rather 
below  the  centre  of  the  outer  or  inner  aspect  of  the  limb,  as  the  case 


*  As  in  railway  and  other  accidents. 

t  If  the  surgeon  is  amputating  very  high  up,  the  method  given  in  the  account  of 
amputation  at  the  hip-joint  (p.  579)  may  be  used. 

t  The  finger  and  thumb  should  not  be  shifted  till  the  anterior  flap  is  marked  out. 


AMPUTATION  THROUGH  TILE  THIGH. 


621 


may  be,  carries  it  rapidly  down  for  about  four  and  a  half  inches,  and 
then  sweeps  it  across  the  limb  with  a  broad,  not  pointed,  convexity,  and 
can-ies  it  up  along  the  side  nearest  to  him  as  far  as  his  thumb.  A  flap 
of  skin  and  fascia  is  then  quickly  dissected  up,  and  the  knife,  being 
sent  across  the  limb,  behind  the  bone,  cuts  a  posterior  flap  almost  as 
long  as  the  anterior,  the  knife  being  used  \vith  a  rapid  sawing  move- 
ment, and  driven  at  first  straight  do^\•n  parallel  with  the  bone,  and  then 
sharply  brought  oiit  through  the  skin. 

The  flaps  being  held  out  of  the  way  ^^•ith  the  surgeon's  left  hand,* 
the  soft  parts  around  the  femur  are  next  severed  with  circular  sweepst 
till  the  bone  is  exposed,  when  one  more  firm  sweep  divides  the 
periosteum,  t 

The  saw  is  now  placed  with  its  heel  on  the  bone  and  drawn  towards 
the  operator  once  or  twice  with  fii'm  pressure  so  as  to  make  one  groove, 
and  one  only.  With  a  few  sharp  sweeps  the  bone  is  next  severed,  care 
being  taken  to  use  the  saw  lightly  for  fear  of  splintering  the  linea 
aspera.  and  to  use  the  ^hole  length  of  the  instrument.     At  this  time 

Fig.  244- 


the  limb  must  be  kept  steady  and  straight,  the  assistant  neither  raising 
it,  which  will  lock  the  saw,  nor  depressing  it,  which  will  splinter  the 
femur  when  this  is  partly  divided. 

If  the  surgeon  decide  to  make  his  posterior  flap  also  of  skin  and  fasciae, 
he  must  have  the  limb  raised,  and  first  looking  over  and  then  stooping 
down,  he  marks  out  a  skin  flap  about  two-thirds  the  length  of  the  an- 
terior ;  this  is  then  dissected  up,  and  the  operation  completed  as  before. 

In  addition  to  the  femoral  vessels,  the  anastomotica.  and  descending 
branch  of  the  external  circumflex,  some  muscular  branches  will  require 
attention ;  and  one  of  these  last  may  give  some  trouble  from  its  position 
close  to  the  bone,  in  contact  \\ith  the  linea  aspera. 

*  And  also  pressed  firmly  upwards,  so  as  to  enable  the  saw  to  be  applied  as  high  ap 
as  possible.     If  the  limb  is  bulky  an  assistant  must  help  here. 

t  This  requires  really  forcible  use  of  the  knife,  the  muscles  behind  the  bone  tending 
to  be  pushed  before  the  knife  rather  than  divided  by  it. 

X  This  final  cut  should  be  a  Uttle  above  the  base  of  the  flaps,  in  order  that  the  savm 
femur  may  lie  well  buried. in  soft  parts. 


622  OPERATIONS  ON  THE  LOWER  EXTREMITY. 

The  following  points  deserve  attention  in  tying  the  femoral  vessels  : 
(i)  Not  to  include  the  saphenous  nerve  ;  (2)  the  tendency  of  the  vessels 
to  slip  up  if  the  point  of  their  division  passes  through  Hunter's  canal ; 
(3)  if  the  vessels  are  atheromatous,  they  must  not  be  tied  too  tightly.  A 
carbolised  silk  ligature,  not  too  fine,  should  be  employed  now,  and  care 
should  be  taken  to  include  a  little  of  the  soft  parts  so  as  to  prevent  the 
ligature  cutting  through. 

In  amputations  of  the  thigh  accompanied  by  grave  shock,  no  needless 
time  should  be  lost  in  looking  for  vessels,  save  the  femoral  and  any  other 
large  branch  which  can  be  seen.  Firm  bandaging  and  raising  the  stump 
will  suffice.  It  is  well  to  partially  relieve  the  tightness  of  the  bandages 
in  a  few  hours  b}^  nicking  them.  Very  few  sutures  should  be  used  in 
these  cases  of  shock,  or  in  those  Avhere  the  soft  parts  are  sinus-riddled. 

II.  Transfixion  Flaps  (Fig.  244). — Advantage.  —  Great  rapidity. 
Disadvantages. — Those  given  at  p.  73,  Vol.  I.,  on  a  large  scale.  This 
method  may  be  used  where  great  speed  is  needed,  as  in  a  double 
amputation  after  a  railway  accident,  or  where  manj^  wounded  require 
attention,  as  after  a  great  battle.  It  is  also  adapted  to  the  wasted 
muscles  of  a  patient  who  has  long  suffered  from  some  chronic  disease  of 
knee  or  leg.  but  even  here  it  is  inferior  to  the  mixed  method. 

Operation. — The  preliminary  steps  given  at  p.  620  being  taken,  the 
surgeon,  standing  to  the  right  side  of  either  limb,  with  his  left  index 
and  thumb  marking  the  site  of  his  intended  bone-section,  raises  with 
his  hand  the  soft  parts  on  the  front  and  sides  of  the  thigh,  and  sends 


Fig 


Circular  amputation  of  the  thigh  to  show  the  greater  retraction  of  the 
muscles  behind. 

his  knife  across  the  limb  in  front  of  the  femur.  The  knife  should  be 
entered  well  below,  so  as  to  get  as  large  an  anterior  flap  as  possible,  and, 
at  its  entry,  should  be  pushed  a  little  upwards  so  as  to  go  easily  over 
the  bone.  An  anterior  flap  is  then  cut  four  to  four  and  a  half  inches 
long,  with  a  broadly  curving  almost  square  extremity,  and  not  too  thin 
at  its  edge.  This  being  raised  by  the  surgeon  or  an  assistant,  the  knife 
is  now  passed  behind  the  bone,  and  a  posterior  flap  cut  of  the  same 
length  as  the  anterior,  the  making  of  this  flap  being  somewhat  facilitated 
by  drawing  the  soft  parts  on  the  back  of  the  limb  away  from  the  bone. 

If  the  liml)  be  very  bulky,  the  knife  should  be  kept  well  away  from 
the  bone,  especially  behind  it,  and  not  as  in  Fig.  244 ;  thus  the  more 
superficial  muscles  only  will  be  included  in  the  posterior  flap. 

Both  flaps  having  been  retracted,  the  remaining  soft  parts  are  severed 
with  circular  sweeps,  and  the  rest  of  the  operation  completed,  as  at 


AMPUTATION  THR0Uf4II  THE  THIGH. 


623 


p.  621,  but  with  this  difFerence,  that  here  there  will  be  more  need  of 
trimming  some  of  the  soft  parts  clean  and  square.* 

III.  The  Circular  Method. — I  may  here  state  brief!}'  why  this  method 
is,  nowadays,  considered  inferior,  both  in  the  thigh  and  elsewhere,  to 
that  by  flaps.  In  saying  this,  it  is  not  denied  that  in  many  cases  stumps 
bj'the  circular  method  are  fully  equal  to  those  by  flaps  ;  indeed,  in  many- 
it  is  impossible  to  tell,  in  later  j^ears,  which  method  has  been  employed. 
On  the  whole,  however,  the  ffap-method  has  the  following  advantages  : 
(l)  It  is  most  generally  applicable — e.g.,  in  most  parts  not  circular 
and  at  the  joints. f  (2)  By  it  the  surgeon  can  better  adapt  his 
skin  covering  to  his  needs — 
e.g.,  when  the  skin  is  less  avail- 
able on  one  aspect  of  the  limb 
than  on  another.  (3)  There  is 
less  risk  of  a  conical  stump  ; 
and  (4)  of  a  cicatrix  adherent 
to  the  bone.  The  great  advan- 
tage of  the  circular  method — 
viz.,  that  the  vessels  and  nerves 
are  cut  square,  and  that,  thus, 
the  former  retracting  more 
easily,  fewer  need  securing, 
while  there  is  less  risk  of 
bulbous  ends  forming  on  the 
latter — is  attained  by  the  mixed 
method  of  skin  flaps  and  cir- 
cular division  of  the  muscles 
as  advised  at  p.  620. i 

The  circular  method  is  only 
to  be  adopted  here  in  the  case  of  the  lower  third  of  wasted  thighs,  or 
in  those   of  3'oung  subjects.     Even  here   the  greater  tendency  of  the 
posterior  muscles  to  retract  (Fig.  245)  must  be  met  by  cutting  them 
about  three-quarters  of  an  inch  longer  than  those  in  front. 

While  this  operation  is  for  the  above  reasons  not  recommended  in 
practice,  it  may  be  made  use  of  in  the  lower  third  of  the  thigh  in  the 
cases  luentioned  above.  On  the  dead  subject  the  student  who  has  not 
had  a  chance  of  performing  it  upon  the  arm  may  make  use  of  it  here. 

Operation. — As  this  method  has  been  described  in  detail  at  p.  77 
Vol.  I.§  it  will  be  only  briefly  given  here.     The  preliminaries  are  those 


Inner  aspect  of  the  stump  of  a  left  thigh,  ampxi- 
tated  by  the  circular  method.  The  powerful 
tendency  of  the  posterior  muscles  to  retract  has 
not  been  allowed  for,  and  the  stump,  in  conse- 
quence, is  conical.     (Farabeuf.) 


*  While  dresser  to  the  late  Mr.  Poland,  I  once  saw  the  femoral  vessels  split  for 
about  three  and  a  half  inches  by  his  rapid  hands.  This  amputation  of  the  thigh  was 
his  last  operation  at  Guy's  Hospital.  He  was  even  then  facing  with  quiet  bravery 
the  bronchitis  which  a  very  few  days  later,  ended  his  life. 

t  To  these  it  may  be  added  that  the  circular  method  is  not  adapted  to  a  case  where 
the  skin  is  matted  to  the  subjacent  muscles. 

J  One  more  advantage  of  the  flap-method  is  the  greater  rapidity,  especially  when 
transfixion  is  employed,  though  this,  in  these  days  of  anesthetics,  is  only  of 
importance  in  a  few  cases. 

§  If  it  be  objected  that  the  plan  here  given  of  turning  up  a  cuff-life  flap  is  likely  to 
lead  to  sloughing,  I  would  reply  that  this  is  not  so  in  these  days  of  antiseptic 
surgery.  If  sloughing  is  dreaded,  a  little  more  time  should  be  taken  in  dissecting  up 
a  thin  layer  of  muscle,  so  as  to  secure  a  deep  fascia  and  thus  a  better  vascular  supply.. 


624  OPERATIONS  ON   THE  LOWER  EXTREMITY. 

already  given.  The  surgeon  standing  to  the  right  of  the  limb,  the 
assistant,  who  stands  on  the  opposite  side  to  him,  but  nearer  the  trunk, 
draws  up  the  skin  with  both  hands.  The  surgeon,  stooping  a  little, 
passes  his  knife  first  iinder  the  limb,  then  above,  across,  and  so  around 
it  till  by  dropping  the  knife  verticall}'  the  back  of  the  instrument  looks 
towards  him,  while  its  heel  rests  on  that  side  nearest  to  him.  He  then 
makes  a  circular  sweep  around  the  thigh,  this  being  aided  by  the  assistant 
who  has  charge  of  the  limb,  rotating  it  so  as  to  make  the  soft  parts 
meet  the  knife.  The  surgeon  then  taking  hold  of  the  edge  of  the 
incision  dissects  up  a  cuff-like  flap,  about  four  and  a  half  inches  in 
length,  cutting  it  of  even  thickness  all  round  the  limb.  The  flap  is 
then  folded  back,  and  the  remaining  soft  parts  divided  AA'ith  circular 
sweeps  of  the  knife.  In  doing  this  the  greater  contraction  of  the  ham- 
string muscles  must  be  remembered  (Fig.  245),  and  these  muscles  cut 
rather  longer  than  those  in  front.  Care  must  be  taken,  if  it  is  thought 
needful,  after  making  the  circular  sweeps,  to  free  the  bone  higher  up, 
and  so  to  secure  its  being  well  buried  in  the  soft  parts,  but  not  to  prick 
the  already  divided  femoral  vessels  which  lie  in  close  proximity  to  the 
femur  in  the  lower  third. 

IV.  Rectangular  Flaps  of  Mr.  Teale. — This  method  is  fully  de- 
scribed ]).  674.  It  is  not  recommended  here  as  it  is  expensive, 
involving  division  of  the  bone  nearer  to  the  trunk  than  other  methods, 
(i)  Owing  to  the  bulkiness  of  the  long  anterior  flap,  it  is,  here, 
especially  difficult  to  fold  and  adjust  it  at  the  conclusion  of  the 
operation,  and,  still  more  so,  to  keep  it  adjusted  if  primarj-  union  fails. 
(2)  Its  chief  advantages — keeping  the  end  of  the  bone  well  buried, 
and  cutting  the  vessels  and  nerves  clean  and  square — are  also 
sufficiently  attained  by  the  other  flap  methods  already  given,  especially 
the  mixed  method  (p.  620). 

V.  Lateral  Flaps. — This  method  has  certain  grave  objections  here, 
(i)  The  sawn  femur,  tilted  upwards  by  the  ilio-psoas,  is  very  liable  to 
press  against  the  upper  angle  of  the  flaps,  and  to  come  through  at  the 
spot  and  necrose.  (2)  If  this  does  not  take  place,  the  bone  often 
adheres  to  the  cicatrix  here,  while  the  flaps  hang  down  and  awa}^ 
from  it. 

It  should  onl}^  be  made  use  of  \\'lien  no  other  method  is  available,  as 
in  a  case  where,  owing  to  the  condition  of  the  soft  parts,  flaps  can  only 
be  got  by  making  one  long  external  and  a  short  interval,  or  vice  versa. 

Operation. — This  method  will  be  found  fully  described  at  p.  673. 


AMPUTATIONS    IMMEDIATELY    ABOVE    THE    KNEE-JOINT 

(Figs.  247-255). 
Methods. 

i.  Garden's  (Figs.  247,  248,  249).  ii.  Gritti's  Trans-condyloid 
(Figs.  250,  252,  254).  iii.  Stokes's  Supra-condyloid,  an  important 
modification  of  the  above  TFigs.  251,  253,  255). 

All  the  above,  but  especially  the  two  latter,  possess  the  following 
advantaijes  (which  they  share  with  amputation  through  the  knee-joint) 
over  amputation  through  the  thigh,  viz. : — 

I.  The  patient  can  bear  his  weight  in  walking  on  the  face  of  his 
stump ;    thus,    he    is    not    compelled   to   take    his    bearing    from    the 


A3IPUTATI0NS  IMMEDIATELY  ABOVE  THE  KNEE-JOINT.     625 

tuberositj^  of  the  ischium,  or  to  walk  as  if  he  had  an  ankylosed  hip-joint 
(Stokes),  as  is  the  case  after  amputation  of  the  thigh,  where  the  stump 
is  ever  liable  to  be  fretted  by  the  slightest  pressure  on  it.  2.  Yeiy  good 
power  of  adduction  over  the  artificial  limb  remains.  Every  surgeon 
miTst  have  noticed  how  badly  otf  a  patient  is  in  this  respect  after  an 
ordinary  amputation  through  the  thigh.  By  these  methods  the 
adductors  are  left  almost  intact,  even  to  part  of  the  strong  vertical 
tendon  of  the  adductor  magnus,  the  result  being  that  the  balance 
between  the  adductors  and  the  abductors  of  the  thigh  remains  practi- 
cally undisturbed,  and  the  patient  when  walking  has  none  of  that 
difficulty  (which  is  seen  after  thigh  amputations)  of  bringing  the  limb 
which  he  has  swung  forwards,  in  again  under  the  centre  of  gravity.* 
3.  The  medullar}^  canal  is  not  opened ;  on  this  account  there  is  less  risk 
of  necrosis  and  osteo-myelitis  if  the  stump  becomes  septic.  4.  There  is 
less  shock,  because  (a)  the  limb  is  removed  farther  from  the  trunk, 
(b)  the  muscles  are  divided  not  through  their  vascular  bellies,  but 
through  their  tendons. 

i.  Garden's  Amputation  (Figs.  247,  248,  and  249). 

Adcantages. — This  valuable  amputation  has  some  points  in  common 
with  Syme's  amputation  at  the  ankle-joint.     In  both  the  bone-section 

Fig.  247. 


(Garden.) 

is  made  not  through  a  medullary  canal,  but  through  vascular,  C|uickly- 
healing  cancellous  tissue  ;  in  both,  the  skin  reserved  for  the  face  of  the 
stump  has  been  used  to  pressure,  though  not  equally  so,  for  the  skin 
preserved  in  the  ankle-amputation  is  thick  and  callous,  in  the  other 
thinner  and  more  sensitive. 

Lord  Lister  [Si/stem  of  Surgerij,  vol.  iii.  p.  705)  thus  recommends 
this  amputation  :  ''  This  operation,  when  contrasted  with  ampiatation  in 
the  lower  third  of  the  thigh,  presents  a  remarkable  combination  of 
advantages.  It  is  less  serious  in  its  immediate  effects  upon  the  system, 
because  a  considerably  smaller  cjuantity  of  the  body  is  removed,  and 
also  because  the  limb,  being  divided  where  it  consists  of  little  else 
than  skin,  bone,  and  tendons,  fewer  blood-vessels  are  cut  than 
when  the  knife  is  carried  through  the  highly  vascular  muscles  of  the 
thigh ;  the  popliteal  and  one  or  two  articular  branches  being,  as 
a  general  rule,  all  that  require  attention,  so  that  loss  of  blood  is  much 
diminished.  In  the  further  progi'ess  of  the  case  the  tendency  to 
protrusion  of  the  bone,  which  often  causes  inconvenience  in  an  am- 
putation through  the   thigh,  is  rendered   comparatively  slight  by  the 

*  The  importance  of  the  preservation  of    the  quadriceps   extensor,  given  by  the 
Stokes-Gritti  method,  need  only  be  alluded  to. 

VOL.    II.  40 


626 


OPERATIONS  OX  THE  LOWER  EXTREMITY. 


ample  extent  of  the  covei^ing  provided,  and  also  by  the  circumstance 
that  the  divided  hamstrings  slip  up  in  their  sheaths,  so  that  the  posterior 
muscles  have  comparatively  little  power  to  produce  retraction.  The 
superiority  of  the  operation  is  equally  conspicuous  as  regards  the 
ultimate  usefulness  of  the  stump,  which,  from  its  great  length,  has  full 
command  of  the  artificial  limb,  while  its  extremity  is  well  calculated  for 
sustaining  pressure,  both  on  account  of  the  breadth  of  the  cut  surface  of 
the  bone  divided  through  the  condyles,  and  from  the  character  of  the 
skin  habituated  to  similar  treatment  in  kneeling.  Considering  therefore 
that  this  procedure  can  be  substituted  for  amputation  of  the  thigh  in 
the  great  majority  of  cases  both  of  injury  and  disease  formerly  supposed 
to  demand  it,  '  Garden's  operation  '  must  be  regarded  as  a  great  advance 
in  surgery."  * 

Disadvanta(jes. — The  chief  of   these    is    the    sloughing    of   the    long 


Fig.  248. 


Fig.  249. 


(Garden.'; 

anterior  flap  which  may  occur,  "  in  spite  of  faultless  operating,"  espe- 
cially if  the  skin,  of  which  it  chiefl}^  consists,  has  been  damaged  by 
injmy  or  disease,  or  if  the  patient  be  old  or  weakl}^  thus  leading 
to  an  adherent,  tender  scar,  and  a  useless  stump. 

Operation. — According  to  its  introducer  this  amputation  consists  in 
removing  a  rounded  flap  from  the  front  of  the  joint  (Figs.  247  and  248), 
dividing  everything  else  straight  down  to  the  bone,  and  sawing  this 
slightly  above  the  plane  of  the  muscles. 

The  operator,  standing  on  the  right  side  of  the  limb,  takes  it,  between 
his  left  forefinger  and  thumb,  at  the  spot  selected  for  the  base  of  the  flap,t 
and  enters  the  point  of  his  knife  close  to  his  finger,  bringing  it  round 
through  the  skin  and  fat  below  the  patella  to  the  spot  pressed  by  his 
thumb,  then  turning  the  edge  downwards  at  a  right  angle  with  the  line 
of  the  limb,  he  passes  it  through  to  the  spot  where  it  first  entered, 
cutting  outwards  through  everything  behind  the  bone.  The  flap  is  then 
reflected,  and  the  remainder  of  the  soft  parts  divided  straight  down  to 
the  bone  ;  the  muscles  are  then  slightly  cleared  upwards,  and  the  saw 

*  Other  advantages  given  by  Mr.  Garden  arc,  the  favourable  position  of  the  stump 
for  dressing  and  drainage ;  its  ijainlcssncss,  the  chief  nerves  being  cut  high  up  and 
slipping  upwards  out  of  the  way  ;  and  the  cicatrix  being  drawn  clear  of  the  point  of 
the  bone,  and  out  of  reach  of  pressure. 

t  This  corresponds  with  the  upper  border  of  the  patella,  the  limb  being  extended. 
The  lower  margin  comes  down  to  the  tubercle  of  the  tibia,  as  in  Fig.  247.  (See  also 
lirit.  Med.  Jonrn.^  1864,  vol.  i.  p.  416). 


AMPUTATIONS  IMMEDIATELY  ABOA'E  TIIE  KNEE-JOINT.     62-j 

applied  "  through  the  base  of  the  condyles."  The  projecting-  part  of  the 
femur  may  be  rounded  off.  Where  there  is  any  doubt  aboiit  the  vitality 
of  the  large  anterior  flap,  a  short  posterior  one  should  be  made,  the 
anterior  one  thus  not  needing  to  be  so  long. 

ii.  Gritti's  Trans-condyloid  (Figs.  250.  252,  and  254).  iii.  Stokes's 
Supra- condyloid  Amputation  (Figs.  251,  253,  and  255). 

For  fuller  information  on  the  above  amputations  I  would  refer  my 
readers  to  a  paper  I  contributed  to  the  Gui/s  IIosp.  Eejjorts,  vol.  xxiii. 
p.  211,  1878,  The  objections  to  amputations  through  the  knee-joint, 
whether  by  a  long  anterior,  or  long  posterior  flap,  are  given  at  p.  632. 
Amputation  through  the  knee-joint  by  lateral  flaps  gives  excellent 
results,  but  in  this  method  the  incisions  are  carried  into  the  leg  below 
the  tibial  tubercle  ;  in  the  two  amputations  mentioned  above  this  level 
is  not  trenched  upon,  and  every  surgeon  knows  that  after  a  severe  com- 
pound fracture  of  the  leg,  an  inch  or  two  more  or  less  of  damage  to  the 
soft  parts  in  the  upper  third  of  the  leg  makes  a  most  important 
difference  as  to  where  he  can  amputate. 

The  two  methods  are  often  confused.  Between  them  there  is  this 
all-im]:)ortant  difference :  in   Gritti's  the  section  of  the  femur  is  made 


Fig.  250. 


Fig.  251. 


Gritti's  traus-coudj'Ioid  section  of  the 
femur,  leaving  a  surface  much  too  long 
and  large  for  the  sawn  patella  to  fit. 


Stokes's  supra-condyloid  section  of  the 
femur,  leaving  a  surface  much  more 
easily  fitted  by  the  sawn  patella. 


through  the  condyles ;    in  Stokes's,  at  least  half-inch  ahove  them.     In 
other  words,  the  one  operation  is  trans-,  the  other  sup'a- condyloid. 

On  this  point  great  stress  has  been  laid,  and  very  rightly,  by  Sir 
W.  Stokes,  and  a  comparison  of  the  two  operations  will  convince  every 
one  that  he  is  correct.  If  the  section  of  the  femur  be  made  through  the 
condyles  (Figs.  250.  252),  the  sawn  patella  will  not  fit  down  into  place. 
It  will  either  be  drawn  up  altogether  on  to  the  front  of  the  femur,  or 
else  Avill  project  forwards,  somewhat  like  the  half-open  lid  of  a  box 
fFigs.  252,  254),  at  an  angle  to  the  broad  sawn  surface,  which  is  also 
too  large  for  it  to  cover,  and  across,  and  off"  which  it  is  liable  to  be 
shifted  by  the  contraction  of  the  quadriceps,  if  it  has  been  found 
possible  to  get  it  into  place.  To  effect  this,  an  amount  of  force  will  be 
required  which  is  almost  certain  to  result  in  bruising  of  the  cut 
periosteum  on  the  edge  of  the  femur,  and  consequent  necrosis.  If, 
on  the  other  hand,  the  saw    is   made    to    pass  a    full   inch  above  the 


628 


OPERATIONS  OX  THE  LOAVER  EXTREMITY. 


condyles  (Fig.  251),  the  patella  will  fall  readily  into  place  (Fig.  253),  it 
will  cover  more  completely  the  now  smaller  surface  of  the  feninr,  and 
will  remain  easily  in  situ  here,  the  flaps  when  brought  together  present- 
ing the  appearance  shown  in  Fig.  255. 

Operation. — An  Esmarch's  bandage  having  been  applied,  the  limb 
brouii-ht  over  the  edge  of  the  table  and  supported,  and  the  opposite  one 


Fig. 


Fig.  254. 


(Farabeuf.) 


The  flaps  in  Gritti's  trans-condyloid  amputa- 
tion, showing  the  patella  hitched  and  requiring 
force  to  adapt  it  to  the  femur,  which  is  now  too 
long  as  well  as  too  broad. 


Fig. 


255- 


secured  out  of  the  way.  the  surgeon,  standing  to  the  right  of  the  limb, 
with  his  left  index  and  thumb  marking  the  base  of  the  flap,  makes  an 
incision  commencing  (on  the  left  side)  an  inch  above  and  rather  behind 
the  external  condyle,  carried  vertically  downwards  to  a  point  opposite  to 

the  tibial  tubercle,  then 
broadly  curved  across  the 
leg  and  carried  upwards 
to  a  point  opposite  to  that 
from  which  it  started. 
This  flap  having  been  dis- 
sected upwards,  together 
with  the  patella  (after 
section  of  the  ligamentum 
patellfe),  a  postei'ior  flap  is 
cut  nearly  as  long  as  the 
anterior.  This  may  be 
effected  in  one  of  two 
ways,  either  by  the  sur- 
geon looking  over  and 
then  stooping  a  little  (the 
limb  being  now  raised),  next  drawing  the  knife  from  without  inwards 
across  the  popliteal  space,  thus  marking  out  and  then  dissecting  up  a  skin 
flap,  or  by  transfixing  and  cutting  the  flap  from  within  outwards.  Of  the 
two  I  pi-efer  the  first :  the  latter  is  the  speedier,  but  less  suited  to  bulky 
limbs.  The  flaps  being  retracted,  the  soft  parts  are  cut  through  with  a 
circular  sweep  a  full  inch  above  the  ai'ticular  surface  of  the  femur,  the 
bone  is  then  sawn  through  here,  and  the  limb  removed.  The  posterior 
sui'face    of  the   patella   is   next  removed  with   a  metacarpal   or   small 


Appearance  of  the  stump  in  a  Stokes-Gritti's  amputa- 
tion. The  patella  has  come  easily  into  place,  The 
drainage-tube  shown  might,  in  many  cases,  be  dispensed 
with, 


REMOVAL  OF  AX  EXOSTOSIS.  629 

Butcher's  saw.  This  last  step  is  the  only  difficult  one  in  the  operation, 
owing  to  the  mobility  of  the  bone ;  it  will  be  facilitated  by  an  assistant 
with  both  his  hands  everting  and  projecting  the  under  surface  of  the 
anterior  flap,  so  as  to  make  the  patella  stand  out  from  it. 

The  vessels — popliteal,  one  or  two  articular,  and  the  anastomotic — 
having  been  secured,  drainage  is  provided,  and  the  flaps  are  brought 
together  with  numerous  points  of  suture,  save  at  the  angles  (Fig.  255). 

Where  the  flaps  are  cut  of  proper  length  and  the  femur  is  sawn  at 
the  proper  height,  it  is  quite  exceptional  for  the  patella  not  to  ride 
easily  hi  situ.  If  there  seem  any  doubt  on  this  point,  or  if  the  patient 
is  verv  muscular,  additional  security  ma}'  be  given — (a)  Bv  passing 
sutures  of  chromic  gut  or  carbolised  silk  between  the  tissues  on  the 
under  surface  of  the  anterior  flap,  at  the  edges  of  the  patella,  and  the 
soft  parts  in  the  posterior  flap  (avoiding  the  vicinity  of  the  large  vessels) ; 
(b)  by  wiring  or  pegging  the  bones  ;  (c)  by  dividing  the  rectus  muscle 
on  the  under  surface  of  the  anterior  flap.  Of  these,  wiring  or  pegging 
is  the  best ;  the  pegs  must  be  scrupulously  clean,  and  should  be  well 
boiled  beforehand.  An  ordinary  bradawl,  also  rendered  aseptic,  will  be 
found  quite  as  efficient  as  a  drill. 


REMOVAL   OF  AN  EXOSTOSIS  FROM   NEAR  THE 
ADDUCTOR  TUBERCLE.* 

As  these  growths  are  by  no  means  uncommon  in  adolescents,  this 
operation  will  be  briefly  described  here.  Aseptic  excision  has  now 
replaced  any  other  operation,  such  as  subcutaneous  fracture. 

Operation. — -The  parts  having  been  thoroughly  cleansed,  the  knee  is 
flexed  so  as  to  bring  down  the  synovial  membrane,  and  the  limb  placed 
on  its  outer  side.  A  free  incision,  about  three  and  a-half  inches  long, 
is  made  over  the  growth,  down  to  the  vastus  internus,  and  any  supei-- 
ficial  vessels  attended  to.  The  muscular  fibres  are  then  cleanly  cut 
through,  and  the  bluish-grey  cartilage  which  caps  the  swelling  now 
comes  into  view.f  Any  muscular  branches  being  now  carefully  secured, 
and  the  wound  sponged  dry,  the  cut  vastus  is  pulled  aside  with  retrac- 
tors, and  the  growth  being  thoroughly  exposed  it  is  shaved  ofl"  with  an 
osteotome  or  chisel,  leaving  exposed  cancellous  tissue.  A  little  iodoform 
is  dusted  in,  and,  if  needful,  drainage  provided  by  a  tube  or  large  horse- 
hair di-ain,  passed  from  the  wound  to  the  most  dependent  spot  on  the 
inner  side,  the  dressing-forceps  passing  under  the  muscle  and  being  cut 
down  upon  b}'  counter-puncture,  where  they  project  under  the  skin. 
The  muscular  fibres  are  then  united  with  chromic  gut,  and  the 
wound  closed  with  separate  sutures.  Strict  aseptic  precautions  are 
taken  throughout  to  secure  primary  union.  The  limb  should  be  kei)t 
absolutely  quiet  on  a  back  splint,  and  a  ^fartin's  bandage  worn,  later, 
for  a  short  time. 


*  This  account  will  serve  for  the  removal  of  other  exostoses — e.ff.,  those  met  with  at 
the  deltoid  insertion,  the  spine  of  the  scapula,  or  the  pelvis. 

t  Any  svnovia-like  fluid  now  escaping  comes  probably  from  a  bursa  over  the  growth, 
not  from  the  joint. 


630  OPERATIONS  OX  THE  LOWER  EXTREMITY 


UNUNITED  FRACTURE   OF  THE  FEMUR. 

The  large  number  of  failures  after  operations  for  tliis  condition  are 
well  known.  The  difficulties  which  may  be  present  during  and  after 
these  operations  are  very  considerable  ;  amongst  them  sufficient 
exposure  of  the  fragments,  keeping  the  wound  aseptic,  and  the  parts  in 
correct  apposition  afterwards  (vide  infra),  are  most  prominent. 

Operation. — On  the  Avhole,  the  introduction  of  pegs  having  been  less 
successfiil,  sub-periosteal  resection  and  fixation  of  the  fragments  is 
indicated  here.'*  This  is  especially  so  in  long-standing  cases,  where 
other  methods  have  failed,  where  there  is  very  little  attempt  at  repair, 
where  an  artificial  joint  exists,  or  where,  after  a  severe  injur}^,  necrosis, 
atrophy  of  the  fragments,  and  fibrous  union  have  followed. 

The  operation  of  resection  should  always  be  performed  with  strict 
aseptic  precautions,  otherwise  the  risks  of  suppuration,  erysipelas, 
osteo-myelitis,  and  pya3mia,  owing  to  the  very  free  incision  required, 
the  exposure  of  cancellous  tissue,  and,  perhaps,  of  the  medullary  canal, 
are  considerable. 

The  following  most  important  preliminary  points  are  given  by  Sir  F. 
Ti'eves  (Oper.  Surg.,  vol.  i.  p.  588J.  "  (i)  It  will  be  well  in  some  cases 
to  apply  extension  for  a  week  or  two  before  the  operation ;  this  over- 
comes the  shortening  produced  by  contracted  muscles,  and  enables  the 
surgeon  to  make  trial  of  the  splint  he  proposes  to  employ  afterwards. 
(2)  Before  undertaking  this  operation  the  surgeon  should  understand 
that  its  success  depends  more  upon  the  completeness  of  the  arrange- 
ments that  are  made  for  keeping  the  bones  in  position  after  the  opera- 
tion than  upon  the  operation  itself,  provided  the  latter  be  carried  out 

Avith  due  care Care    in   the    adjusting  of  the   fragments,  and 

infinite  and  continued  care  in  the  after-treatment,  are  the  main  elements 
of  success  in  the  present  class  of  case.  (3)  In  dealing  with  a  fracture 
of  the  femur  in  an  adult,  it  is  well  that  the  operation  be  performed  as 
the  patient  lies  upon  the  bed  he  will  occupy  throughout  the  whole 
treatment.  Much  moving  of  the  patient  after  the  operation  is  very 
undesirable,  and  a  long  thigh-splint  without  extension  apparatus  can- 
not be  conveniently  applied  upon  the  operation  table.*'  The  limb 
having  been  rendered  bloodless,  if  practicable,  with  Esmarch's  bandages,! 
the  fracture  is  exposed  by  a  free  incision,  five  to  six  inches  long,  on  the 
outer  side  of,  and  going  down  to,  the  bone.  The  periosteum  is  next 
most  carefully  detached  from  the  ends  of  the  fragments,  and  a  thin  la^'er 
of  bone,  about  a  quarter  of  an  inch  in  thickness,  removed  from  each.    To 


*  Lord  Lister  has  recorded  (^Brit.  Med.  Journ.,  Aug.  26,  1871)  the  case  of  an 
ununited  extra-capsular  fracture  of  the  femur  in  a  man,  aged  45,  where,  eighteen 
months  after  the  injury,  he  cut  down  on  the  fragments,  with  antiseptic  precautions, 
and  gouged  them,  the  fracture  being  then  Jinally  put  up.  Recovery  was  complete,  the 
man  walking  well. 

t  This  step  is  condemned  by  some,  notably  by  Sir  F.  Treves  (Joe.  supra  cit.,  p.  588), 
I  admit  that  it  leads  to  much  oozing  from  the  cut  surfaces,  but,  having  tried  both 
ways,  I  am  of  opinion  that  this  can  be  safely  met  by  applying  ample  well-adjusted 
dressings  before  the  bandage  is  removed,  and  that  the  advantage  of  a  bloodless  wound 
during  a  most  difficult  and  prolonged  operation  is  almost  incalculable. 


UXUXITED  FRACTURE   OF  THE  FEMUR.  63 1 

facilitate  the  resection,  the  fragments  may  be  thrust  out  of  the  wound, 
or,  after  the  removal  of  the  periosteum,  dragged  out  and  steadied  witli 
sequestrum-forceps  before  the  saw  is  applied.  The  soft  parts  must  be  pro- 
tected with  spatulse  and  retractors  while  the  ends  of  the  bone  are  removed 
with  a  narrow-bladed  saw.  The  fragments  are  now  brought  into  exact 
apposition,  and  to  facilitate  this  it  may  be  necessary  to  divide  adhesions 
or  tendons,  or  to  remove  any  intervening  fibrous  or  fibro-cartilaginous 
material,  or  a  sequestrum.  If  the  fragments  are  successfully  adjusted 
and  carefully  kept  so  (vide  stqj'ra),  the  use  of  wire,  pegs,  and  screws 
may  be  dispensed  with.  Their  use,  although  it  ensures  correct 
apposition  of  the  fragments,  prolongs  and  complicates  the  operation, 
and  may  give  considerable  trouble  later  on.  If  it  be  determined  to 
make  use  of  wire,  the  ends  are  now  to  be  drilled,  the  drill  being  entered 
on  the  sujDerficial  surface  of  each  fragment,  and  then  made  to  project  in 
the  centre  of  the  medullary  canal.  They  are  next  held  together  by 
passing  xerj  stout  *  silver  wire  through  the  drill-holes,  and  twisting  this 
up.  If  the  wire  is  to  be  removed,  three  or  four  half-twists  or  two 
complete  twists  should  be  sufficient.  If  the  surgeon  prefer,  he  may 
hammer  it  down,  in  situ,  having  made  three  half-twists  and  cut  the 
ends  short.  See  the  remarks,  p.  654.  Other  methods  that  may  be  found 
superior  to  wire  are  Mr.  W.  A.  Lane's  screws,  p.  68^,  (Clin.  Soe.  Tran.^., 
1894J,  and  Prof.  Senn's  hollow  perforated  bone  cylinders  or  ferrules. 
These  are  circular  or  triangular,  and  large  enough  to  slip  easily  over  the 
fragments.  The  most  accessible  fragment  having  been  sufficiently 
isolated,  the  ferrule  is  slipped  over  it  and  far  enough  away  from  the 
line  of  fracture  to  clear  the  other  fragment.  After  reduction  has  been 
accomplished  the  second  fragment  is  engaged  in  the  ring,  which  is  then 
pushed  back  sufficiently  far  to  grasp  both  fragments  securely.  If  the 
ferrule  rides  too  loosely,  any  space  should  be  packed  with  chips  of  decal- 
cified bone.  The  limb  is  put  up  in  plaster  of  Paris.  If  suppuration 
occur,  the  ferrules  are  removed  by  cutting  through  one  side  with  bone 
forceps,  after  enlarging  the  sinus,  when  the  parts  are  consolidated.  If 
there  is  no  suppuration,  the  ferrule  will  probably  be  absorbed  (Ann.  of 
Surg.,  vol.  ii.  1893,  P-  125). 

The  special  bone  clamp  devised  by  Dr.  Clayton  Parkill  has  also  been 
used  successfully  in  a  number  of  cases.  A  full  account  of  the  clamp 
and  its  various  uses  is  given  in  the  Ann.  of  S".r<j..  ^lay  1898.  Here 
will  be  found  also  the  reports  of  fourteen  cases  in  which  the  clamp  has 
been  used.  The  fact  that  success  was  obtained  in  each  of  these  cases 
constitittes  a  strong-  claim  for  a  more  extended  trial. 


*  About  one-tenth  of  an  inch  in   thickness,  so  as  to  withstand  the  strain  of  the 
muscles  of  an  adult  thigh. 


CHAPTER  IV. 
OPERATIONS   INVOLVING   THE   KNEE-JOINT. 

AMPUTATION  THROUGH  THE  KNEE-JOINT.  —  EXCISION" 
OF  THE  KNEE-JOINT.— ARTHRECTOMY  OF  THE  KNEE- 
JOINT.— WIRING  THE  PATELLA.— REMOVAL  OF  LOOSE 
CARTILAGES  FROM  THE  KNEE-JOINT.  —  SLIPPED 
FIBRO-CARTILAGES. 

AMPUTATION    THROUGH    THE    KNEE-JOINT    (Fig.   256). 

Chief  Methods. 

I.  By  Lateral  Flaps.  II.  By  Long  Anterior  and  Short  Posterior 
Flaps. — Of  these  the  first  is  far  the  superior.  The  great  objection  to 
the  second  is,  that  in  order  to  get  sufficient  covering  to  fall  readily  over 
the  large  condyles,  a  long  anterior  flap  must  be  cut ;  as  this  must  reach 
two  inches  below  the  tibial  tubercle,  a  good  deal  of  its  blood-supply 
which  comes  from  below — e.g.,  from  the  recurrent  tibial,  must  be  cut 
off,  and  the  flap  is  thus  liable  to  slough.  This  risk  is  much  diminished, 
and  the  blood-supply  better  equalised,  by  the  method  of  lateral  flaps. 

I.  Amputation  by  Lateral  Flaps. — This,  the  method  of  Dr.  Stephen 
Smith,*  was  brought  before  English  surgeons  by  Mr.  Bryant,  f  The 
femoral  artery  having  been  controlled,  the  limb  supported  over  the  edge 
of  the  table,  and  slightly  flexed,  the  surgeon,  standing  on  the  right  side 
of  either  limb,  marks  out  two  broad  lateral  flaps  as  follows :  His  left 
thumb  and  index  finger  being  placed,  the  former  over  the  centre  of  the 
head  of  the  tibia,  the  latter  at  the  corresponding  point  behind,  opposite  the 
centre  of  the  joint,  he  marks  out  (in  the  case  of  the  right  limb)  an  inner 
flap  by  an  incision  which,  commencing  close  to  the  index  finger,  is 
carried  down  along  the  back  of  the  limb  for  about  three  inches  and  a  half, 
and  then  curves  upwards  and  forwards  across  the  inner  aspect  of  the  leg, 
till  it  ends  in  front  just  below  the  thumb.  %     The  knife  not  being  taken 

*  Ncrv  York  Jorirn.  of  Med.,  Sept.  1852  ;  Amer.  Journ.  Med.  Sou,  Jan.  1870. 

t  Med.-Chir.  Trans.,  a'oI.  Ixix.  p.  163. 

X  Dr.  S.  Smith  begins  his  incision  about  an  inch  below  the  tubercle  of  the  tibia, 
and  carries  it  up  rather  higher  behind — viz.,  to  the  centre  of  the  articulation.  It  will 
be  found  easier  to  open  the  joint  and  to  detach  the  semilunar  cartilages  from  the 
tibia  by  making  the  incision  as  recommended  above. 


AMPl'TATIOX  THROUGH  THE   KNEE-JOINT. 


633 


Fig.  256. 


off,  a  similar  flap  is  then  shaped  from  the  outer  side,  lout  in  the  reverse 
direction.  Dr.  .Stephen  Smith  calls  attention  to  the  following  points : 
In  making  these  flaps,  they  should  be  cut  broad  enough  to  secure  ample 
covering  for  the  condyles,  and  the  inner  one  should  be  made  additionally 
full  as  the  internal  condyle  is  longer  than  the  external.  The  flaps  should 
be  at  least  three  inches  and  a  half  long,  if  of  equal  length.  They  con- 
sist of  skin  and  fasciae.  When  they  have  been  raised  as  far  as  the  line 
of  the  articulation  the  ligamentum  patellas  is  severed,  allowing  the  patella 
to  go  upwards.  The  soft  parts  around  the  joint  are  then  cut  through 
with  a  circular  sweep,  and  the  leg  removed.  In  doing  this,  the  limb  being 
flexed  to  relax  the  parts  and  facilitate  opening  the  joint,  the  semilunar 
cartilages  will  very  likeh'  be  found 
closely  encircling  the  condyles  of 
the  femur.  Mr.  Bryant,  in  the  paper 
already  quoted,  and  Dr.  Brinton 
(Philad.  Med.  Times,  Dec.  28,  1872), 
as  long  ago  as  1872,  have  strongly 
advised  that  the  semilunar  cartilages 
should  be  left  in  situ  by  severing  the 
coronary  ligaments  which  tie  them  to 
the  tibia.  They  thus,  in  Dr.  Brin- 
ton's  words,  form  "  a  cap,  fitted  on 
the  end  of  the  femur,  which  pre- 
serves all  the  fascial  relations,  effec- 
tually prevents  retraction,  and  guards 
against  the  projection  of  the  con- 
dyles." This  precaution  will  obviate 
a  serious  objection  to  amputation 
through  the  knee-joint.  For  a  time 
the  patient  bears  his  weight  well  on 

the  end  of  the  stump.  But  after  some  months  the  ends  of  the  condyles 
(if  unprotected  by  the  menisci)  begin  to  fret  the  thin  overlying  skin, 
and  within  a  year  of  the  amputation  the  patient,  usually,  has  to  have 
his  artificial  limb  altered. 

Mr.  Pick's  (Med.  Soc.  Proc,  1884,  vol.  vii.  p.  134)  modification  of  the 
above  operation  is  twofold — viz.  (i)  He  begins  his  incision  higher  up — 
i.e.,  at  the  upper  border  of  the  patella;  and  (2)  he  removes  the  patella. 
This  last  would  a])pear  likely  to  run  the  risk  of  damaging  the  blood- 
supply. 

II.  By  a  Long  Anterior  and  a  Short  Posterior  Flap. — The  position 
of  the  patient  and  the  surgeon  being  as  at  p.  632,  the  latter  with  his  left 
index  and  thumb  on  either  side  of  the  interval  between  the  femur  and 
tibia,  enters  his  knife  (in  the  case  of  the  right  limb)  just  below  the 
finger  and  internal  condyle,  carries  it  straight  down  along  the  inner  side  of 
the  leg  till  it  reaches  a  spot  two  inches  below  the  tibial  tubercle,*  then 
squarely  across  the  leg  till  it  reaches  a  corresponding  point  well  back 
upon  the  outer  side,  and  thence  up  to  a  point  just  below  his  thumb,  or 
to  the  external  condyle.     This  flap  is  then  dissected  up,  containing  the 

*  Mr.  Pollock  (^Mcd.-Cliir.  Trans.,  vol.  liii.  p.  20)  advises  that  the  anterior  flap  should 
reach  "  quite  five  inches  below  the  patella."  It  is  diflScult  to  see  how  sloughing  can 
he  avoided  here,  so  much  of  the  blood  to  this  very  long  flap  coming  from  below  and 
IjeinK.  of  necessitv.  cut  off. 


Amputation  through  knee-joint  by  lateral 
The  incision  has  been  begun  un- 
usually low  down.     (Bryant.) 


634  OPERATIOXS  ON  THE  LOWER  EXTREMITY. 

patella,  as  thickly  as  possible,  and  almost  rectangular  in  shape,  an}'- 
thing  like  pointing  of  its  lower  end  being  most  carefully  avoided,  as 
certain,  to  lead  to  sloughing. 

This  flap  being  raised,  a  posterior  flap  is  made  about  two-thirds  the 
length  of  the  first,  as  at  p.  628,  either  by  dissection  from  without  in- 
wards, or  by  transfixion  after  disarticulation. 

EXCISION*   OF  THE  KNEE-JOINT 

(Figs.  257  and  258). 

Indications. — A.  For  Disease.     B.  Injury. 

A.  (i.)  Pulpy.     Tubercular  knee. 

This  condition,  being  the  most  frequent  indication  for  excision  of  the 
knee,  calls  for  most  careful  consideration  of  the  following  points : — 

(i)  Safety  and  Amount  of  Rish. — Lord  Lister's  treatment,  by  re- 
moving sepsis,  has  rendered  excision  of  the  knee  practically  safe  in 
properly  selected  cases.  No  surgeon  who  is  familiar  with  careful  anti- 
septic treatment  and  excision  of  the  knee  will  say  that  the  above  is  too 
strong  a  statement.f  Excision  here  contrasts  very  sharply  with  the 
same  operation  at  the  hip,  from  the  much  greater  facilities  for  getting 
away  all  the  disease  at  the  time,  and  for  getting  at  and  examining  the 
wound  later,  together  with  the  greater  ease  with  which  the  wound  here 
is  kept  aseptic. 

(2)  A(je. — Here  the  operation  has  to  be  considered — {a)  as  a  substitute 
for  amputation  ;  Qi)  as  a  substitute  for  the  expectant  treatment.  While 
excision  may  be  successfully  employed  at  any  age  up  to  thirt}-,  and  even 
occasionally  in  older  :j:  patients,  I  consider  the  most  favourable  j^ears  ta 
be  from  about  fifteen  to  twenty.  Before  fifteen,  and  particularly  before 
ten,  we  have  especially  to  consider  the  effect  of  the  operation  on  the 
growth  of  the  bone  ;  after  twenty  we  have  more  and  more  to  consider 
the  condition  of  the  patient,  the  state  of  the  viscera,  general  vitality, 
&c.  I  would  ask  my  reader's  careful  attention  to  these  points — (i)  that 
the  chief  growth  of  the  femur  takes  place  at  its  lower  end  (p.  594) ; 
(2)  that  by  fifteen,  and  still  more  by  seventeen,  the  growth  of  the  bone 
is  largely  completed.  It  follows  from  the  above  remarks  that  in  young 
subjects,  especially  before  ten,  as  little  of  the  bones  as  possible  should 
be  removed,  and  that  gouging  should  largely  replace  the  saw. 

(3)  Bank  of  Life. — Excision  of  the  knee  being  almost  unknown  in 
private  practice,  it  is  needless  to  remark  that  this  account  of  the  operation 

*  This  operation  is  contrasted  with  arthrectomy  of  the  knee  at  p.  650. 

t  I  may  perhaps  here  say  that  up  to  1S97  I  excised  the  knee  seventy-seven  times,  and 
performed  arthrectomy  on  eighteen  occasions.  Of  the  cases  of  excision  four  died  of 
effects  of  the  operation,  one  (mentioned  below)  from  shock,  another  (also  mentioned 
below)  from  threatening  gangrene,  a  third  from  surgical  scarlet  fever,  and  the  fourtli 
from  septicaemia.  The  child  with  surgical  scarlet  fever  was  moved,  during  my  absence 
from  town,  into  an  empty,  chilly  ward;  the  eruption  became  dusky  and  then  sup- 
pressed ;  coma,  followed  by  death,  ensued.  Six  have  been  submitted  to  amputation, 
making  good  recoveries.  This  number  would  probably  have  been  seven,  as  a  patient, 
aged  53,  whose  knee  had  been  excised  for  disorganisation  after  osteo-arthritis  and 
whom  I  had  advised  to  submit  to  amputation,  went  out  able  to  walk  a  little  with  a. 
stick,  but  with  two  sinuses. 

%  See  the  remarks  on  osteo-arthritis  (p.  637). 


EXCISION  OF  THE  KNEE.  635 

refers  almost  entirely  to  hospital  patients.  Let  me  briefly,  though 
imperfectly,  depict  the  usual  fate  of  these  patients  with  pulpj^  knee  if 
not  exceed  earlij.  Bandied  about  from  one  out-patient  room  to  another, 
treated  more  or  less  imperfectly  with  splints  and  strapping,  frequently 
recommended  for  admission  that  they  may  obtain  that  '"  rest "  which 
can  nowhere  else  be  carried  out.  at  last  the  ••  dresser  for  the  week,"  or 
surgeon,  takes  pity  on  the  case  and  it  is  admitted.  With  what  result  ? 
As  soon  as  the  inflammation  has  subsided  and  the  pain  has  ceased,  the 
child  is  thought  to  be  occupying  a  bed  which  can  be  better  employed 
for  clinical  teaching,  and,  after  a  few  weeks'  rest  in  bed,  is  turned  out 
again,  perhaps  in  plaster  of  Paris  or  a  Thomas's  splint.  A  little  later, 
in  the  rough-and-tumble  life  of  the  courts  and  alleys  of  our  large  towns, 
the  joint  is  wrenched,  and  the  good  gained  is  all  undone.  Suppuration 
now  sets  in  at  one  or  more  points  of  the  pulpy  tissue,  sinuses  form,  the 
ends  of  the  bone  become  carious,  and  the  condition  of  the  joint  from  the 
now  advanced  stage  of  the  disease,  and  its  probably  septic  condition,  is 
rendered  far  less  favourable  for  any  operation  than  it  was  at  an  earlier 
stage.  To  speak  briefly,  believing,  as  I  do,  that  in  this  rank  of  life 
excision  will  be  needed  in  nine  cases  out  of  ten,  I  am  of  opinion,  most 
distinctly,  that,  as  soon  as  a  pulpy  condition  is  declared,  excision  or 
erasion  (or,  if  needed,  both  combined)  should  be  performed  while  the 
state  of  the  joint  and  the  general  condition  of  the  patient  are,  alike, 
favourable. 

If  the  surgeon  desires  to  have  a  time-limit  at  which  it  is  justifiable 
to  resort  to  excision  he  may  remember  the  dictum  of  ]\[r.  Howse  {Gm/s 
Hosp.  Beports,  1894) :  "  When  a  well-marked  case  of  pulpy  disease  has 
lasted  over  six  months,  it  is  not  worth  while  to  attempt  the  conserva- 
tion of  the  joint  for  a  longer  period."  Under  these  conditions  "  we  best 
consult  the  patient's  interests  by  excising  the  joint  on  these  grounds : 
(i)  That  the  chances  are  very  much  in  favour  of  the  continued  progress 
of  the  disease ;  (2)  That  even  if  the  disease  does  not  progress  it  will 
leave  a  damaged  weakened  joint,  very  liable  to  outbreaks  of  trouble ; 
(3)  That  by  means  of  the  operation  the  duration  of  the  treatment  is  so 
very  much  shortened,  reducing  to  a  few  months  wliat  would  otherwise 
take  as  many  years  ;  (4)  And,  finally,  because  by  means  of  it,  we  greatly 
reduce  the  risk  of  tubercular  infection,  which  results  from  the  absorp- 
tion of  caseating  products."' 

(4)  Valve  of  the  Lirnh. — This  qucestio  vexata  of  thirty  ^-ears  ago  is  now 
largely  settled.  Very  few  will,  nowadays,  be  found  to  dispute  which  is 
most  serviceable,  a  limb,  though  much  shortened,  with  a  natural  foot, 
or  an  artificial  leg,  especially  of  the  kind  supplied  to  hospital-patients 
after  amputation  of  the  thigh.  On  this  subject  some  remarks  of  Mr. 
Holmes  (Sxrg.  Di<.  of  Cldldren,  p.  497)  may  be  quoted  :  "Even  if  we 
allowed  that  a  patient,  after  successful  excision  of  the  knee,  coidd  only 
walk  as  fast  and  as  far  as  some  with  a  good  artificial  limb  after  amputa- 
tion, this  would  still  leave  the  operation  of  excision,  in  my  mind,  far  the 
superior  one.  since  the  former  patient  can  do  by  his  own  force,  without 
any  preparation  and  without  any  expense,  what  the  latter  can  only  do 
by  the  aid  of  the  instnmient-maker.  I  need  hardly  say,  however,  that 
this  is  a  gross  understating  of  the  case.  A  patient,  after  excision  of 
the  knee,  can  often  walk  nearh*  as  fast  and  nearly  as  far  as  he  could 
before.     The  patient,  after  amputation  of  the  thigh,  however  well  the 


636  OPER:iTrONS  OX  THE  LOAVER  EXTREMITY. 

case  ma}'  have  clone,  can  rarely  bear  the  fatigue  of  carrying  the  artificial 
limb  many  miles  together,  nor  can  there  be  an}^  reasonable  comparison 
of  the  agility  of  the  two — at  least  in  those  cases  where  the  foot,  after 
excision,  comes  nearl}'  on  to  the  ground,  and  is  in  good  position."  As 
to  those  cases  where  the  limb  is  flail-like  and  its  growth  seriously 
arrested,  I  would  point  out  that  the}'  should  hardly  ever  occur,  with  the 
improved  treatment  of  wounds,  the  greater  facilities  with  which  a  stiff 
apparatus  of  a  simple  kind  can  nowadays  be  supplied,  our  more  exact 
knowledge  of  the  epiphyses,  and  the  substitutes  for  the  saw  which 
are  read}'  to  our  hands  in  the  shape  of  sharp  spoons  (p.  640).  I 
may  also  refer  ni}'  readers  to  Sir  W.  Fergusson's  Hunterian  Lectures, 
Lecture  VI.,  and  his  arguments  in  favour  of  a  much-shortened  limb  over 
any  artificial  one.* 

(5)  Condition  of  the  Patient. — I  may  refer  ni}"  readers  to  the  remarks 
on  this  point  on  excision  of  the  hip,  p.  594.  There  is  the  same  need 
here  for  examining  for  any  evidence  of  lardaceous  disease,  or  tubercular 
mischief,  elsewhere,  and  to  remember  how  latent  and  insidious  these 
ma}'  be.  Bone  mischief  elsewhere  is  not  necessarily  prohibitive.  Three 
out  of  my  seventy-seven  cases  (p.  634)  had  had  spinal  disease,  well- 
marked  bosses  remaining  in  all.  Each  of  them  made  an  excellent 
recover}'.  Strumous  disease  of  the  tarsus  existed  in  two  others,  and  was 
cured  by  the  time  the  knee  was  well.  In  two,  disease  of  the  hip  co- 
existed on  the  same  side ;  in  one  the  limb  had  eventually  to  be  removed 
by  a  Furneaux  Jordan's  amputation,  the  child  recovering ;  in  the  other 
(the  disease  being  on  the  opposite  side)  the  knee  after  a  trans-patellar 
excision  did  excellently,  the  hip  disease  being  cured  by  rest. 

(6)  StaiJG  of  the  Disease. — I  have  already  shown  (p.  635)  that  I  am 
a  strong  advocate  lor  early  excision  in  hospital  cases,  believing  that, 
with  the  usual  treatment,  short  of  this,  puljjy  disease  goes  on,  as  a  rule, 
inveterately  from  bad  to  worse.  But  in  early  life  excellent  results  may 
be  obtained,  even  in  advanced  cases  with  sinuses  and  caries,  by  excision, 
if  onl}^  all  the  diseased  and  septic  material  is  got  away. 

It  will  be  useful  to  some  of  my  readers  if,  before  leaving  the  subject 
of  tubercular  disease,  I  quote  the  opinion  of  one  of  the  first  living 
authorities  on  excision  of  the  knee,  Mr.  Howse  (Gufs  Hosp.  Rejmis, 
1894):  "In  answer  to  the  question,  *  In  what  cases  should  excision 
be  performed  ?  '  we  should  say :  (a)  Certainly  in  all  cases  in  which  the 
disease  has  advanced  so  far  as  to  cause  flaking  of  the  articular  cartilage 
or  grating  in  the  movement  of  the  joint,  whether  suppuration  be 
present  or  no.  (8)  Cases  in  which  backward  displacement  of  the  tibia 
has  taken  place.  (7)  All  cases  of  over  six  months'  duration,  in  which 
there  is  reason  to  .believe  that  the  disease  has  started  in  an  epiphysial 
osteitis.  (8)  Cases  of  extensive  suppuration  in  the  joint  starting  from 
pulpy  mischief.  (e)  Cases  in  which  the  pulpy  infiltration  of  the 
synovial  membrane  has  advanced  to  any  considerable  degree  over  the 
articular  cartilage.  (^)  Cases  in  which  pulpy  infiltration  has  extended 
beyond  the  capsular  ligament  to  the  crucial  ligaments  and  semilunar 

*  Mr.  H.  Lee  {Lancet,  1888,  vol.  i.  p.  769)  published  the  results,  after  twenty  years, 
of  two  cases  of  excision  in  boys  of  twelve  and  seven.  In  the  first  the  leg  was  nine 
inches,  in  the  second  six  inches  shorter  than  its  fellow.  Both  patients  had  perfect  use 
of  the  muscles  of  the  leg  and  foot,  and  could  walk  all  day  with  a  light  iron  patten 
attached  to  a  boot.     Such  shortening  is,  nowadays,  unknown. 


EXCISION  OF  THE  KNEE.  637 

cartilages."  In  the  first  four  the  condition  and  the  need  of  excision  are 
alike  obvious.  If  in  the  last  two  difficult}'  of  diagnosis  arises,  the  time 
limit  of  six  months  will  be  found  of  most  value. 

The  same  aiithority  gives  (ihuL)  the  conditions  in  cases  of  "pulpy 
knee "  which  call  for  immediate  amputation.  They  are :  A.  Con- 
stitutional ;  and  B.  Local.  A.  Constitutional,  (a)  Lardaceous  disease. 
(yS)  Tubercular  disease  of  the  lung  or  other  viscus.  (7)  Great 
emaciation  without  any  very  evident  visceral  disease.  (B)  Multiple 
joint  disease  (vide  p.  636).  B.  Local.  (a)  Osteitis  or  periostitis 
extending  far  up  the  shafts  of  either  femur  or  tibia,  as  shown  bj'  great 
thickness  or  tenderness  of  the  bone.*  (/3)  A  er}^  great  infiltration  of 
pulpy  material  into  the  soft  parts,  extending  far  beyond  the  limits  of 
the  joint. 

(ii)  Threatening  disorganisation  of  the  knee,  with  caries,  after 
pya3mia,  infective  arthritis,  etc. 

(iii)  Osteo-arthritis. — Where  one  joint  only  is  affected,  and  the 
patient  is  not  past  middle  life,  excision  gives  good  results.  The 
surgeon  must  be  prepai'ed  for  sawing  very  dense  bones. 

(iv)  Ankylosis. — I  think  excision  should  be  abandoned  here  for  the 
far  better  operation  of  dividing,  with  aseptic  precautions,  the  union, 
with  an  osteotome  introduced  first  on  one  side  and  then  on  the  other, 
and  worked  forwards  under  the  patella,  and  skin,  and  backwards  as  far 
as  the  popliteal  arterj'  allows.  If  this  fail,  a  double  osteotomy  of  the 
femur  and  tibia  should  be  performed  rather  than  excision,  an  operation 
Avhich,  in  the  case  of  true  bony  ankylosis,  is  liable  to  be  severe,  pro- 
longed, and  to  leave  a  large  wound,  and,  in  the  case  of  young  subjects, 
to  lead  to  further  shortening  of  a  limb  already  atrophied  and  weakened 
from  disease.  As  I  shall  not  have  space  again  to  refer  to  this  matter  of 
ank^^losis  of  the  knee,  I  would  strongly  urge  caution  in  rapidly  and 
completely  straightening  a  knee-joint  which  has  long  been  the  seat  of 
a  bom"  ankylosis  in  a  bad  position.  My  attention  was  drawn  to  this 
matter  in  a  painful  way  about  seven  years  ago.  A  girl  of  19  had  been 
admitted  under  my  care  with  bony  ankylosis  of  the  knee  at  a  right 
angle,  dating  to  disease  seventeen  years  before.  Finding  that  I  was 
unable  to  materially  improve  the  position  by  subcutaneously  sawing 
through  the  bony  union,  I  excised  the  joint  and  straightened  it  com- 
pletely. The  foot  and  leg  remaining  cold,  an  anaBsthetic  was  given  next 
day,  and  the  limb  put  up  flexed.  The  mischief  was,  however,  done. 
The  coldness  remained,  all  pulsation  in  the  tibials  stopped,  and 
gangrene  evidently  threatening,  the  thigh  was  amputated,  the  patient 
sinking  afterwards.! 

At  the  necropsy,  osteophytes  were  found  on  the  posterior  border  of 
the   tibia  projecting  backwards,   and  it  was    evident  that  over  these, 

*  Mr,  Howse  points  out  that,  occasionally,  tenderness  and  thickening  may  be  due  to 
a  sequestrum,  which  may  be  successfully  removed,  and  later  on  a  useful  limb  obtained 
by  excision. 

t  Just  after  this  another  London  surgeon  published  a  very  similar  case.  SuflScient 
attention  has  not  been  drawn  to  this  matter.  It  would  have  been  much  wiser  on  my 
part,  with  such  dense  and  old-standing  ankylosis,  not  to  have  attempted  complete 
straightening  at  once,  but  to  have  straightened  partly  with  an  osteotome  at  first,  and 
then  to  have  completely  rectified  the  position  later.  I  have  adopted  this  mode 
successfully  since,  in  a  much  older  patient,  with  almost  as  much  contraction. 


638  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

when  the  limb  was  straightened,  the  popliteal  vein,  a  very  small  one, 
had  been  stretched  and  closed. 

(v)  Old,  Neglected  Infantile  Paralysis. — Excision  of  the  knee  seems 
to  me  to  be  perfectly  justifiable  here,  with  a  view  of  giving  a  firm 
support  in  the  case  of  a  limb  useless  from  its  flail-like,  distorted  state. 
I  speak  here  of  hospital  cases,  which  furnish  those  miserably  crippled 
lives  which  are  still  seen  from  time  to  time  going  the  round  of  the 
hospitals. 

I  have  during  recent  years  been  making  use  of  operative  measures 
largely  in  these  cases,  following,  as  far  as  the  principle  goes,  my  old 
friend,  G.  A.  Wright,  of  JNIanchester,  and  Mr.  R.  Jones,  of  Liverpool. 
Everyone  \\'ho  has  seen  much  of  these  cases,  with  their  dangling,  flail- 
like  limbs,  going  from  hospital  to  hospital  for  courses  of  electricity  and 
medicine,  quickly  outgrowing  or  breaking  expensive  apparatus,  obtained 
at  much  cost  of  time  and  trouble — anyone  who  lias  taken  the  trouble 
of  watching  the  after-history  of  these  cases,  and  has  realised  how  often 
they  come,  when  adolescent,  to  amputation  on  account  of  persistent 
trophic  sores  ap])earing  on  the  useless  limb,  must  have  wished  that 
some  operative  steps  could  be  devised  which,  at  a  cost  of  a  few  months, 
might  make  these  early  aftlicted  patients  less  of  an  encumbrance  to 
others.  The  only  question  is  what  operation  is  best  adapted  to  render 
the  flail-like  knee  and  ankle  sufliciently  firmly  fixed  to  bear  their  share 
of  the  weight  of  the  body.  G.  A.' Wright  (Ahstrartx  of  Gases  treated 
in  the  Peiidlehuni  Hospital,  1884)  records  the  case  of  a  girl,  aged  14, 
in  which  he  excised  the  knee  and  ankle  in  such  a  case  with  good 
results.  Mr.  R.  Jones  (Prov.  Med.  Journ.,  Dec.  1894  and  Jan.  1895) 
recommends  a  modified  erasion,  opening  the  joint,  peeling  off  all  the 
cartilage  in  the  case  of  the  ankle,  and,  in  addition,  gouging  the  bone  in 
that  of  the  knee.  While  I  agree  with  Mr.  Jones  that  excision  involves 
a  greater  sacrifice  than  an  already  shortened  limb  can  spare,  I  maintain 
that  by  itself  this  operation  is  insuflicient.  If  we  are  to  do  any  good 
with  these  advanced  and  confirmed  cases  of  infantile  paralysis,  we  must 
replace,  somehow,  the  flail-like  limb  by  a  useful  firm  support  early  in 
life,  before  puberty.  Now,  I  have  in  several  cases  tried  excision  or 
erasion  of  knee  and  ankle,  and  have  found  that  in  such  a  limb  the  joints 
do  not  unite  firmly  enough  ;  the  result,  if  watched,  is,  therefore,  not 
sufficiently  good.  The  reason  is  not  far  to  seek.  In  early  life,  if  only 
small  sections  are  removed  with  the  saw — and  no  more  is  permissible 
for  fear  of  further  serious  interference  with  the  length  and  growth  of 
the  already  dwarfed  and  dwindled  limb — the  bone  surfaces  are  scant 
and  puny,  the  rims  of  cartilage  are,  relatively,  very  large.  Here  the 
conditions  needful  for  firm  union  are  absent,  and  I  have  found  excision 
or  erasion  alone  of  the  knee  and  ankle  does  not  entirely  remove  the 
flail-like  condition  of  these  joints.  In  two  cases  I  have  gone  farther,  and 
in  addition  to  excising  the  knee  I  have  passed  Mr.  W.  A.  Lane's  screws 
between  the  tibia  and  femur,  and  after  all  the  cartilage  has  been 
removed  from  the  surfaces  of  the  tibia,  fibula,  and  astragalus,  have 
]iassed  stout  silver  wire  between  the  tibia  and  astragalus.  These  cases 
have  been  thus  operated  on  about  five  months.  The  foreign  bodies 
have,  so  far,  given  no  trouble,  and  the  stability  of  the  limbs  is 
greatly  improved.  The  time  that  has  elapsed  is  not  sufficient  for 
one    to    speak    confidently,    but    the    result    is     certainly  sufficiently 


EXCISION  OF  THE  KXEE.  639 

encouraging  for  nie  to   call  the  attention  of  my  professional  brethren 
to  it. 

B.  Injury. — Here  such  injuries  as  those  from  gunshot  and  those 
from  a  lacerated  wound  or  a  compound  fracture,  must  be  considered 
separately. 

1.  Gunshot. — "The  results  of  the  excisions  of  the  knee-joint,  per- 
formed during  the  late  civil  war,  whether  the  operations  were  primary, 
intermediary,  or  secondary,  were  not  very  encouraging,  forty-four  of 
the  fifty-four  cases  in  which  the  issues  were  ascertained  having 
terminated  fatally,  a  mortality  of  8r4  per  cent.,  exceeding  the  mortality 
of  the  ami)utations  of  the  thigh  (53"8)  by  27'6  per  cent.  "  (Otis,  loc. 
supra  cii.,  p.  419).  Sir  T.  Longmore  (Si/st.  of  Surg.,  vol.  i.  p.  565)  lays 
down  these  definite  rules:  "From  all  the  experience  which  has  been 
gained  regarding  gunshot  wounds  in  which  the  knee-joint  has  been 
opened,  especially  if  the  surfaces  of  the  bone  have  escaped  damage, 
as  may  occasionally  happen  with  modern  narrow  rifle  bullets,  and  even 
in  other  cases  where  one  of  the  bones  has  been  fissured,  or  partial 
fracture  has  occurred,  provided  early  immobilisation  of  the  injured 
parts  can  l3e  secured,  antiseptic  treatment  carried  out,  and  the  general 
surroundings  are  sufficiently  hygienic,  it  maj'  now  be  laid  down  as  a 
rule  that  conservative  treatment  ought  to  be  adopted.  When,  however, 
the  circumstances  under  which  the  wounds  have  been  inflicted  are  such 
that  the  precautionary  methods  and  modes  of  treatment  mentioned 
cannot  be  put  into  practice,  when  the  patients  are  liable  to  be  moved 
frequentl}'  or  to  long  distances  hurriedly,  and  without  adequate 
protection,  or  when  the  joint  is  not  only  penetrated,  but  the  sur- 
rounding coverings  are  much  lacerated,  or  the  bones  are  comminuted 
and  the  fragments  completelj-  detached,  the  sacrifice  of  the  limb  by 
amputation  abo^-e  the  joint  is  the  only  measure  calculated  to  afford  a 
fair  promise  of  safety  of  life  to  the  patient." 

2.  Injuries  other  than  gunshot. — Excision  is  rarely  practicable  here. 
A  very  careful  consideration  of  the  local  and  general  conditions  present 
is  needful.  Amongst  the  former,  damage  limited  to  the  articular 
surfaces,  but  little  splintering  of  the  shafts  of  the  bones,  an  intact 
condition  of  the  softs  parts  behind  the  joint  are  absolutely  essential. 
Not  less  important  is  it  to  weigh  the  more  general  points  connected 
with  the  patient — viz.,  his  age  not  reckoned  by  years  only,  the  condition 
of  his  viscera,  and  his  habits  ;  all  these  points  are  attended  to  in  the 
account  of  "The  Treatment  of  Compound  Fractures,"  given  later  on. 

Operation. — Before  and  throughout  an  excision  of  the  knee  the 
operator  should  bear  in  mind  the  following  points :  (i)  To  remove  every 
atom  of  the  disease  ;  (2)  to  secure  good  drainage ;  (3)  to  leave  the  bones 
in  good  position  ;  (4)  to  ensure  absolute  immobility  afterwards  ;  (5)  to 
watch  for  and  at  once  attack  any  relapse.  The  more  I  perform  this 
operation,  the  more  do  I  feel  the  truth  of  the  words  of  Prof.  Bruns. 
of  Tubingen,  that,  while  formerh'  its  chief  object  was  to  remove  all 
dead  bone,  it  should  now  be  considered  of  chief  importance  to  remove 
all  the  tulierculous  material  that  can  possibly  be  got  awa}-,  and  that  the 
surgeon  should  not  content  himself  with  snipping  away  all  he  can, 
leaving  the  rest  to  caseate  or  become  scar-tissue  if  it  will,  but  pursue  it 
with  the  same  earnest  aim  of  extermination  as  he  would  in  the  case  of 
malignant  disease.     I  would  not  by  the  above  seem  to  speak  slight- 


640  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

ingly  of  the  value  of  securing  liealthy  and  correctly  sawn  surfaces  of 
bone,  as  on  these  largelj^  depends  firm  ankylosis  and  a  sound  and  useful 
limb,  but  I  would  insist  on  the  fact  that  such  surfaces  are  secured  in 
vain  if  pulpy  material  is  allowed  to  remain,  and  that  it  is  not  as  yet 
sufficiently  recognised  that  other  instruments — e.g.,  sharp  spoons  and 
scissors  curved  on  the  f3at — are  to  the  full  as  useful  as  the  saw. 

Mr.  Howse  takes  a  different  view  of  the  importance  of  exterminating 
tubercular  material  (loc.  supra  cit.)  :  ''  In  thus  advising  the  only  partial 
removal  of  the  pulp,  it  is  necessar}'  to  recollect  the  changes  of  which  it 
is  capable.  Many  surgeons  treat  it  as  if  it  were  a  tumour  formation, 
the  success  of  the  case  depending  upon  its  complete  removal  or 
destruction.  That  is,  I  am  sure,  a  mistake.  Pulpy  material  in  its 
after-history  is  susceptible  of  three  changes,  (i)  It  may  be  simply 
absorbed,  just  as  anj^  inflammatory  material  disappears  by  the  process 
of  resolution  ;  (2)  it  may  undergo  caseation  by  the  process  of  starvation 
in  the  way  already  described;  or  (3)  it  may  organise  and  become 
converted  into  good  fibrous  tissue."  I  can  only  say  that  with  regard  to 
the  first  and  the  third  of  the  above,  my  experience  has  been  much  less 
happy  than  my  colleague's  ;  with  the  second  or  caseation  we  are  all,  of 
course,  familiar  wherever  the  tubercular  material  be  met  with.  I 
repeat  that,  whether  in  glands  in  the  neck  or  in  the  synovial  membrane 
of  joints,  it  should  be  treated  once  for  all,  if  possible,  thoroughly, 
determinately.  and  with  the  same  earnest  aim  of  extermination  as  in 
the  case  of  malignant  disease. 

Before  the  time  of  the  excision,  any  flexion  of  the  knee  should  be 
corrected  as  far  as  possible  by  careful  weight-extension.  A  knee  should 
never  be  excised  while  flexed.  Such  a  step  will  only  be  liable  to  lead 
to  removing  bone  needlessly  in  order  to  straighten  the  limb.  The  risk 
of  gangrene  has  been  already  mentioned  (p.  637). 

The  parts  having  been  duly  cleansed,  and  an  Esmarch's  bandage  * 
applied  at  mid-thigh,  the  limb  is  brought  over  the  edge  of  the  table, 
flexed,  and  held  by  an  assistant  as  in  Fig.  259. 

From  the  moment  of  commencing  the  operation  to  its  very  close  the 
surgeon  must  bear  in  mind  the  inveteracy  of  tubercular  pulpy  material 
(malignancy  would  probably  not  be  too  strong  a  word),  and  in  his 
endeavours  to  extirpate  the  disease  completelj^,  both  in  the  soft  parts 
and  in  the  bones,  his  operation  must  often  combine  the  operations  of 
erasion  and  excision. f 

The  following  modes  of  exposing  the  joint  will  be  given  here  : 

A.  Transverse,   Removing  the  Patella.      B.   Transverse,'  through. 

*  Some  object  to  the  bandage  as  needless  and  as  likely  to  lead  to  troublesome  oozing 
after  the  operation.  This  may  be  met  by  firm  pressure  and  even  bandaging  on  of  the 
dressings,  so  as  to  distribute  any  oozing  evenly  throughout  them.  If  an  Esmarch's 
bandage  is  not  applied,  the  bleeding  during  the  operation  interferes  with  the  removal 
of  diseased  tissues,  requires  constant  pressure  to  arrest  it,  and  taxes  the  patient's 
resources  considerably.  Its  use  meets  another  risk,  which  is  possibly  hypothetical, 
and  that  is,  it  renders  impossible  the  general  diffusion  of  tubercular  material  by  the 
cut  veins  and  lymphatics.  Two  Esmarch's  bandages  must  not  be  applied  if  there  is 
any  risk  of  rupturing  a  pulpy  capsule,  or  where  the  capsule  has  given  way  and  septic 
sinuses  exist. 

t  If  operations  for  pulpy  knee  are  resorted  to  at  an  earlier  stage  in  hospital  patients- 
the  bones  will  less  and  less  need  interfering  with. 


EXCLSrOX   OF  THE   KXEE. 


641 


the  Patella..  C.  The  Semilunar  Flap  (lately  recommended  by  Mr. 
Barker,  and  attributed  by  him  to  Moreau). 

A.  Transverse,  Removing  the  Patella  (Fig.  257).  This,  the  older 
method,  is  still  resorted  to  by  those  surgeons  who,  like  ]\[r.  Howse, 
believe  that,  if  the  patella  is  retained,  a  most  serious  risk  is  run  of 
leaving  behind  pulpy  material  which  will  require  removal  later  on  under 
less  favourable  circumstances,  and,  this  failing,  may  lead  to  amputation. 

The  surgeon,  standing  on  the  left*  side  of  the  diseased  knee  (the 
opposite  limb  being  tied  to  the  table)  makes  an  incision  right  across  the 
joint  from  the  back  of  one  condyle  to  that  of  the  other.f  Tliis  incision 
passes  over  the  lower  part  of  the  patella  and  divides  the  lateral  ligaments 
at  once.  The  soft  parts  being  then  dissected  up  for  two  inches  above 
the  patella,  so  as  to  expose  the  supra -patellar  pouch,  deep  incisions  are 


Fig.  257. 


Fig    258. 


Trans-patellar  excision, 

made  above  and  below  the  patella,  which  is  then  removed  and  the  joint 
opened. 

If  the  patella  is  ankj^losed  to  the  condyles,  it  must  be  removed  by  a 
blunt  elevator,  aided  by  a  narrow  saw,  or,  better,  by  an  osteotome  and 
mallet.  No  violence  should  be  used  in  opening  a  joint  partially 
ankylosed,  or  the  epiphyses  may  easily  be  separated  from  the  shaft, 
especially  in  a  child. 

I  invariably,  when  raising  the  flap  of  soft  parts  in  an  excision  of  the 
knee,  however  performed,  slit  them  up  by  a  vertical  incision,  going  to 
the  upper  limit  of  the  supra-patellar  pouch,  so  as  to  expose  fully  all  its 
folds  and  recesses.    Unless  this  is  done,  pulp}-  material  is  very  easil}^  left 


*  This  position  renders  it  much  easier  for  him  to  saw  the  femur  and  tibia. 

f  Beyond  this  spot  the  incision  should  not  go,  for  fear  of  wounding  the  internal 
saphena  vein.  This  would  lead  to  troublesome  oedema  of  the  foot  and  leg,  and,  if  the 
wound  should  become  septic,  might  bring  about  septic  phlebitis  and  pyaemia. 

VOL.  11.  41 


642  OPER.ITIOXS  OX  THE  LOWER  EXTREMITY. 

behind,  and,  later  on  breaking  down,  leads  to  oedema,  persistent  sinuses, 
perforation  of  the  pouch  and  spread  of  disease  amongst  the  adductors 
and  into  the  \dcinit3^  of  the  femoral,  and  perforating  vessels  where  it  is 
impossible  to  eradicate  it,  amputation  being  eventually  called  for. 

B.  Transverse,  through  the  Patella  (Fig.  258). — This  method,  by 
preserving  the  patella  and  the  insertion  of  the  quadriceps,  partly 
counter-balances  the  flexing  action  of  the  hamstrings  (p.  648)  at  the 
same  time.  Used  b}'  Volkmann  many  years  ago,  it  was  again  brought 
under  the  notice  of  English  surgeons  by  Mr.  Golding  Bird  in  a  case 
which  he  brought  before  the  Clinical  Society  (Trans.,  vol.  xvi.  p.  82). 

For  arguments  against  preserving  the  patella  I  must  refer  my  readers 
to  Mr.  Howse's  article  (loc.  supra  cit.).  I  am  of  opinion,  myself,  that  in 
young  subjects  where  the  union  is  prone  to  bend  for  some  time,  it  is 
well  worth  while  to  preserve  the  patella,  though,  to  insure  the  full 
benefit  of  this  step,  fresh  osseous  surfaces  should  be  prepared  on  this 
bone  and  on  the  femur  and  tibia  so  as  to  promote  bony  union.  Another 
and  minor  argument  in  favour  of  preserving  this  bone  is  that  the 
anastomoses  about  the  joint  are  less  interfered  with. 

The  transverse  incision  is  made  here  much  as  in  the  first  method,  onh' 
across  the  middle  of  the  patella ;  this  is  sawn  through  or  divided  with  a 
stout  knife,  the  fragments  turned  up  and  down,  and  the  joint  freel}' 
opened  (Fig.  258). 

C.  Semilunar  Flap  (Moreau,  Barker). — Here  a  large  U-shaped  flap 
is  raised  by  a  semilunar  incision,  stai'ting  above  one  condyle,  descending 
to  the  level  of  the  tibial  tubercle,  crossing  the  leg  here  and  running  up 
to  a  corresponding  point  on  the  other  side.  In  raising  this  flap,  which 
includes  all  the  soft  parts  down  to  the  bone,  either  the  ligamentum 
patellas  should  be  severed  (suturing  of  this  being  resorted  to  later),  or 
the  tuberosity,  attached  to  the  ligament,  is  removed  with  a  chisel,  and 
subsequently  wired  down  (Barker). 

The  joint  having  been  opened  b}^  one  of  the  above  incisions,  it  is  well 
to  slit  with  a  sharp  bistoury  the  supra-j^atella  pouch*  up  to  its  upper 
limits  (readilj^  reached  by  a  finger),  so  as  to  lay  bare  every  crevice  and 
to  remove  ever}-  atom  of  diseased  tissue.  The  cut  margins  being 
held  on  the  stretch  b}'  two  Spencer  Wells's  forceps,  the  surgeon  with 
mouse-toothed  forceps  seizes  the  cut  edge  of  the  synovial  lining  of  the 
capsule,  and  with  curved  scissors  removes  it  in  one  piece,  first  from 
under  the  vasti  muscles  and  then  along  its  reflexion  on  to  the  femur 
down  to  where  it  ceases  at  the  margin  of  articular  cartilage. 

Next  the  lateral  and  crucial  ligaments  are  examined,  and  every 
particle  of  diseased  tissue  removed,  only  bright,  glistening,  clearly 
healthy  ligamentous  tissue  being  left.f  I3ut  as  naked-eye  examination 
in  parts  perhaps  not  absolutely  bloodless  may  easily  be  fallacious,  it  is 
much  better  in  doubtful  cases  to  remove  these  completely  than  to  run 
any  risk  Avhatever.     The  assistant  who  is  in  charge  of  the  limb  now 

*  I  look  on  this  as  one  of  the  most  cardinal  points  of  the  operation. 

t  Prof.  Oilier  Qloo.  infra  cif.  and  Eiv.  de  Chir.,  1882)  drew  attention  to  preserving 
the  lateral  ligaments,  if  possible,  together  with  all  healthy  periosteum  and  capsule — 
i.e.,  those  tissues  which  will  keep  the  bones  in  place  and  which  will  tend  to  produce 
ossifying  material.  This  will  not  interfere,  if  carefully  carried  out,  with  extirpating 
diseased  parts,  while  it  will  go  far  to  prevent  progressive  flexion  of  the  joint. 


EXCISION  OF  THE   KNEE. 


643 


brings  the  head  of  the  tibia  well  into  view  by  pulling  the  calf  of  the  leg 
well  forward  with  one  hand  while  he  further  dislocates  the  bone  b}^ 
pushing  up  the  leg  (Fig.  259). 

The  condition  of  the  semilunar  cartilages  is  next  examined,  and  if 
they  are  invaded  by  pulpy  tissue,  P^^.   ^ 

or  if  it  is  intended  to  perform  a 
complete  excision,  they  must  be 
cut  awa}"  entirely. 

The  back  of  the  joint  is  next 
taken  in  hand.  This  region  can 
be  far  more  effectively  dealt  with 
after  removal  of  the  bones.  If, 
owing  to  the  case  being  an  earh" 
one,  with  little  or  no  caries,  the 
surgeon  desires  to  remain  con- 
tent with  an  erasion,  he  must 
still  deal  thoroughly  with  the 
posterior  ligament*  and  deeper 
parts  of  the  sides  of  the  joint 
with  all  recesses  and  folds  of 
the  synovial  membrane.  To 
expose  these  parts  thoroughly 
is  a  matter  of  some  difficulty. 
The  assistant  should  manipu- 
late the  lindj  as  above  directed 
at  one  time,  at  another  iiex  the 
leg  back  towards  the  table, 
while  occasionally  a  finger  in 
the  popliteal  space  will  keep 
within  reach  any  altered  tissue 
that  it  is  desired  to  deal  with. 
Every  pains  must  be  taken  to 
use  the  scissors  systematically 
and  thoroughlj^  here  as  else- 
where, until  healthy  tissues  are 
reached,  and  not  to  dread  the 
popliteal  arterj^  too  much.  This 
should  be  enforced  for  two 
reasons.  If  any  diseased  tissue 
is  left  here,  it  will  be  shut  in 
after  the  limb  is  extended  and  be  impossible  to  deal  with,  save  by  a 
fresh  and  probalily  imsuccessful  operation.  Again,  there  is  always  a 
risk,  especially  in  a  surgeon's  earlier  operations,  of  his  not  dealing 
with  disease  here  with  sufficient  thoroughness  from  dread  of  injuring 
the  popliteal  artery.  This  vessel  nia}^  be  avoided  b}^  (i)  not  dipping 
the  points  of  the  scissors  deeply,  but  using  the  blades  as  far  as  possible 
parallel  with  the  course  of  the  vessel;  (2)  by  remembering  that  even 
after  the  posterior  crucial  ligament  has  been  thoroughly  cleansed  (a 
matter  often  imperfectly  done)  there  is  still  a  considerable  thickness 
of  tissue  in  front  of  the  artery. 

*  This  and  the  pobteiiur  parts  of  the  bcmiluuar  fibro-cartilages  arc  liable  to  be 
inefficicutly  treated. 


644 


OPERATIONS  ON  THE  LOWER  EXTREMITY. 


Fig.  260. 


After  all  diseased  tissues  at  the  back  have  been  thoroughly  eradicated, 
the  deeper  aspects  of  the  sides  of  the  joint  must  be  examined.  In  one 
case  I  was  imable  to  satisfy  myself  that  the  limits  of  the  diseased  tissues 
were  reached  till  the  tendons  of  the  semi-tendinosus  and  semi-mem- 
branosus  came  into  view  ;  and  in  another,  that  of  the  sartorius,  caseating 
foci  having  spread  down  beneath  the  fascia  on  the  inner  side  of  the 
joint.  If  an  erasion  is  thought  sufficient,  the  surgeon,  having  gone  over 
the  synovial  membrane  svstematically  and  in  detail,  now  attends  to  the 
bones.  With  a  stout,  sharp  scalpel,  he  scrapes  or  pares  off  from  the 
cartilaginous  surfaces  of  femur  and  tibia  any  adherent  pulpy  material, 

removing  thin  shavings  of  the  cartilage 
where  needful.  This  must  be  carried 
out  to  the  very  back  of  the  condyles 
and  throughout  the  intercondyloid 
notch,  and  around  the  posterior  aspect 
of  the  head  of  the  tibia. 

It  now  remains  to  describe  the  re- 
moval of  the  bones  in  case  erasion  is 
not  sufficient.  Thus,  excision  will  in 
future  be  probably  called  for  onlj'"  in 
cases  of  long  standing,  where  caries  is 
present,  and  in  those  with  sinuses  and 
suppuration.  Where  excision  is  evi- 
dently^ needed,  the  bones  should  be 
sawn  after  the  supra-patellar  pouch  is 
cleared  out,  and  before  the  posterior 
aspect  of  the  joint  is  taken  in  hand,  as  this  step  will  be  much  facilitated 
thereby. 

The  femur,  held  as  steady  as  possible,  is  taken  first.  A  groove  for  the 
saw  is  first  so  marked  out  with  the  scalpel  as  to  remove  about  one-third 
of  the  condyles.  In  severer  cases,  or  where  the  above  section  will 
clearly  be  insufficient,  half,  or  even  two-thirds,  of  the  articular  surface 
may  be  removed,  but  no  section  should  be  made  farther  back  than  this, 
or  the  epiphysis  will  be  trenched  upon  with  serious  after-results.*  Care 
should  be  taken,  in  making  the  section  of  the  femur,  to  ensure  that 
the  plane  of  the  sawn  surface  shall  be  at  right  angles  to  the  axis 
of  the  shaft.  Mr.  Howse  prefers  to  saw  the  femur  while  this  is  held 
vertically. 

The  tibia  is  taken  next,  and  a  groove  marked  out  with  the  knife 
about  half  an  inch  below  the  articular  cartilage.     A  Butcher's  saw,  set 


*  Dr.  HofEa,  of  Wurzburg  (^Arch.  f.  Min.  Chir.,  Band  xxii.  Heft  4,  1885  ;  Annals  of 
Surgery,  March  1886),  brings  forward  cases  to  show  that  removal  of  both  epiphyses 
led,  at  the  end  of  ten  years,  to  shortening,  amounting  to  25^  cm.  (i  cm.  =  ^  inch), 
while  in  another  case  it  amounted  in  two  years  to  10  cm.  Loss  of  the  femoral 
epiphysis  alone  showed  17  cm.  of  shortening  in  six  years,  and  7  cm.  in  a  year  and  a 
half.  Two  cases  of  the  like  duration  affecting  the  tibial  line  showed  respectively 
15^  and  6  cm.  It  is,  however,  well  known  that  considerable  shortening  may  occur  in 
cases  treated  expectantly.  Dr.  Hoffa  found  in  one  case  with  ankylosis  at  an  angle 
that  at  the  end  of  twelve  years  the  shortening  amounted  to  18  cm. ;  in  nine  other  such 
cases,  ranging  in  duration  from  one  to  eight  years,  the  shortening  varied  from  i  to 
I3i  cm.,  with  angular  contraction  in  most  cases,  and  with  very  marked  atrophy  and 
trophic  disturbances. 


EXCISION   OF  THE  KNEE. 


645 


Fig.  261. 


horizontally,  is  used  from  behind  forwards,  and  on  a  perfectly  level 
plane.  Neither  here  nor  in  sawing  the  femur  must  the  slightest 
wobbling  of  the  saw  be  permitted. 

About  half  an  inch  only  of  the  tibia  should  be  removed,  just  enough 
in  fact  to  expose  health}-  cancellous  tissue,  and  no  more.  Of  the  femur, 
no  more  than  an  inch  and  a  half  should  be  removed  if  possible.*  Any 
soft,  yellow,  cheesy,  fatty  patches,  am-  cancellous  tissue  into  which  pulpy 
tissue  has  dipped  after  perforating  the  cartilage,  should  be  carefully 
removed  with  a  gouge.  "Where,  however,  there  is  much  caries  or  the 
above  patches  are  numerous,  breaking  down  readily  under  the  finger- 
nail, more  than  one  slice  of 
bone  had  better  be  removed. 

The  whole  wound  is  now 
finally  most  carefully  scruti- 
nised, eveiy  outlying  angle 
and  recess  being  examined 
for  pulpy  tissue  left  behind. 

The  Esmarch's  bandage  is 
now  by  some  removed,  and, 
while  sterile  pads  wrung  out 
of  hot  I  in  2000  hydr.  perch. 
are  held  firmly  over  the  sawn 
tibia,  any  bleeding  points  in 
the  upper  half  of  the  wound 
are  attended  to.  The  safest 
way  of  arresting  the  bleeding  is 
b}'  underrunning  with  chromic 
gut  and  fine  needles  all  the  vessels  which  spirt,  as  practised  by  Mr. 
Howse  ;  or  Mr.  Barker's  plan  (yi/le  infra),  which  I  greatly  prefer,  may 
be  tried.  Bleeding  from  the  cancellous  tissue  will  be  arrested  by 
placing  the  bones  in  contact.f  If  there  is  any  tendency  of  the  edges 
of  the  skin  to  fold  in,  these  must  be  shortened. 

The  best  means  of  arresting  the  lijemorrhage,  and  one  which  I  have 
followed  in  all  my  later  cases  of  excision  and  erasion.  is  that  advised  by 
Mr.  Barker  (Hunt.  Lect.,  supra  cit.).  The  Esmarch's  bandage  is  here 
not  removed  until  the  dressings — a  thick  layer  of  iodoform  gauze,  sal- 
alembroth  or  salicylic  wool,  or  wood  wool — are  firmly  bandaged  in 
position.  To  admit  of  sufficient  pressure  being  applied  to  check  the 
oozing  and  to  distribute  it  evenly  through  the  dressings,  a  white  bandage 


*  Very  much  larger  amounts  may  be  removed  if  needful,  especially  in  children  and 
young  adults,  with  good  reparative  power.  If  the  surgeon  is  obliged  to  trench  upon 
the  epiphyses  it  should  be  with  the  gouge,  and  not  with  the  saw,  if  possible.  In  one 
case  of  a  boy,  aged  7,  the  bones  being  carious,  soft,  and  fatty,  a  large  patch  of  cheesy, 
fatty  bone  presented  itself  in  tne  head  of  the  tibia  after  the  first  slice  had  been 
removed.  On  removing  this,  the  gouge  entered  the  medullary  canal,  which  was 
exposed,  gaping  on  the  sawn  surface.  I  was  doubtful  how  far  union  would  take  place 
here,  but  three  years  later  the  boy  had  a  most  useful  limb,  probably  from  a  ring  of 
epiphysial  tissue  being  left. 

t  The  following  vessels  will  be  found  to  give  the  chief  trouble  after  a  combined 
erasion  and  excision  :  One  or  two  running  down  in  the  periosteum  over  the  femur,  one 
or  two  in  the  cut  periosteum  surrounding  the  sawn  margin  of  the  tibia,  and  one  from 
the  azygos  articular  in  the  posterior  ligament. 


646 


OPERATIOXS  OX  THE  LOA\'ER  EXTREMITY. 


Fig.  262. 


peo-oino-. 
have  been 


should  first  be  applied  from  tlie  foot  to  the  upper  third  of  the  leg.     If 

one  of  !Mr.  Howse's  splints  is  employed,  the 
Esmarch's  bandage  must  be  applied  suffi- 
ciently high  up  the  thigh  not  to  interfere 
with  the  limb  being  placed  in  the  splint, 
as  this  has  to  be  done  before  the  dressings 
are  applied.  I  have  found  this  plan  most 
satisfactory. 

The  patella,  if  sawn,  is  now  drilled  and 
^^•ired.  or  united  with  stout  silk  or  chromic 
gut.  I  prefer  the  first,  the  wive  being  left 
long  and  removed  in  about  a  fortnight. 

The  question  now  arises  whether  the  tibia 
and  femur  should  be  united  by  wiring  or 
'■•  *  I  am  of  opinion  that  if  the  bones 
so  sawn  as  to  bring  their  faces 
squarely  together,  with  sufficiently  exact 
closeness  to  prevent  more  than  a  finger- 
nail being  inserted  between  them,  and  if 
they  are  put  up  with  the  securit}^  which  is 
given  by  Mr.  Howse's  method,  the  above 
aids  are  not  needed. f  Failure  of  excision 
is  due  not  to  deficiency  of  repair  in  the 
bones,  but,  as  a  rule,  to  persistency  of  pulp}', 
tubercular  material. 

The  need  of  drainage  must  vary  with  the 
experience  of  the  operator.  If  tlie  bone 
surfaces  are  well  together,  if  the  angles  of 
the  wound  are  left  open,  and  if  aseptic  pre- 
cautions have  been  taken  throughout,  drain- 
age is  rareh"  required.  Two  or  three  sutures 
may  be  made  use  of  in  the  middle  of  the 
incision,  the  sides  being  always  left  open. 
Before  closing  the  wound,  I  rub  a  little 
sterilised  iodoform  over  the  different  sur- 
faces, and  dry  these  scrupulously,  when  the 
sutures  are  in  place,  Mr,  Howse's  splint  is 
now  applied.  To  those  who  are  not  familiar 
with  the  most  excellent  method  devised  by 
nn'  colleague,  the  following  brief  account]: 
may  be  useful.  The  arrangement  will  be 
found  most  simple,  and  equally  efficient  in 
admitting  of  antiseptic  dressing  and  maintaining  the  parts  in  absolute 
rest.     The  splint  consists  of  two  interrupted  tinned-iron  troughs    for 


This  aud  the  next  figure  shows 
the  line  of  the  epiphyses  which 
enter  into  the  knee-joint,  seen 
from  the  front.  That  of  the  fibula 
is  also  .seen.  They  are  taken 
from  a  well-grown  subject  of 
about  18.     (Farabeiif.) 

Fig.  263. 


*  The  bones  have  been  united  with  difEerent  forms  of  pegs  or  nails,  or  by  wire,  stout 
carbolised  silk,  or  chromic  gut. 

t  I  may  be  speaking  with  insufficient  knowledge,  but  I  am  under  a  strong  impression 
that  the  advocates  of  these  aids  have  not  made  trial  of  the  absolute  fixity  ensured  by 
a  vrell-applicd  Howse's  splint  (^vide  infra).  Mr.  Morrant  Baker's  and  Mr.  Howard 
Marsh's  methods  of  fixing  the  bones  by  steel  or  bone  pins  will  be  found  in  the  Brit. 
Med.  Joiirn.,  1887,  vol.  i.  pp.  321,  389, 

%   Gmfit  Ho»p.  Reports  i877r  vol,  xxii,  p.  503,  and  the  accompanying  plate. 


EXCISION'   OF  THE  ICsEE.  647 

the  thigh  and  leg  joined  by  a  posterior  bar.  This  is  from  four  to 
six  inches  long,  according  to  the  age  of  the  patient ;  it  is  convex  from 
side  to  side  to  avoid  cutting  into  the  popliteal  space,  and  can  be 
lengthened  or  shortened  if  any  alterations  in  the  interruption  are 
reqiiired.     At  the  end  of  the  splint  is  an  adjustable  foot-piece. 

The  limb  being  laid  in  the  splint,  attention  must  be  paid  to  the 
posterior  bar  being  in  the  centre  of  the  popliteal  space,  the  foot  must 
be  well  down  on  the  foot-piece  ;  if  the  splint  grips  the  thigh  or  leg  too 
tightly  or  rides  too  loosely,  it  must  be  bent  out  or  in  with  iron  "  crows." 
The  dressings  are  now  applied,  preferably  those  of  iodoform  gauze, 
wrung  out  of  carbolic-acid  lotion,  and  wool.  Great  care  must  be  taken 
to  bandage  from  below  upwards  and  from  within  outwards,  the 
bandage  being  laid  on  evenly  and  firmly  so  as  to  distribute  the  dis- 
charges, evenly,  right  through  the  dressings,  and  to  prevent  their 
coming  through  at  one  or  two  spots.  The  splint  is  next  secured  to  the 
limb  with  "  waxed  bandages,"  prepared  by  passing  them  through  a 
mixture  of  ordinary  yellow  wax  and  olive  oil,  in  proportions  sufficient  to 
make  the  wax  soft  and  workable.  After  they  are  applied  to  the  leg  and 
thigh  they  are  painted  over  with  a  little  hot  wax  mixture,  so  as  to  make 
them  weld  into  one  mass.*  The  limb,  thus  secured,  is  slung  with  cord 
and  pulley  to  Howse's  modification  of  Salter's  cradle.  This  occupies  the 
lower  part  of  the  bed  ;  the  patient  lies  on  a  half  water-bed. 

The  chief  points  now  are  (i)  to  ensure  as  absolute  immobility  as 
possible ;  (2)  to  employ  as  infrequent!  dressings  as  practicable ;  (3)  to 
watch  for  every  sign  of  relapse,  and  to  attack  it  as  soon  as  noticed. :j 

After-treatment. — Morphia  or  laudanum  should  be  used  freely  at 
first,  if  needful.  If  the  temperature  keep  do'v^Ti,  the  dressings  should 
be  left  undisturbed  for  two  weeks,  when  an  anaesthetic  may  be  given,  if 
needful,  to  remove  the  wire  if  the  excision  has  been  a  trans-patellar  one, 
take  out  any  drainage-tubes,  and  also  to  make  sure  that  there  ai'e  no 
persistent  sinuses  pointing  to  a  residual  pulpy  material.  These,  if 
found,  must  be  slit  up  with  a  sharp-pointed  curved  bistoury,  and  scraped 
out  with  a  sharp  spoon.  While  this  may  be  repeated  every  two  weeks, 
on  five  or  six  occasions  successfully,  the  more  deliberately  the  surgeon 
endeavours  to  extirpate  the  disease  both  in  the  soft  parts  and  in  the 
bones,  the  more  he  treats  it  as  if  malignant  at  first,  the  less  often  will  he 
have  to  interfere  later  on. 

In  about    three  months,   Mr.  Howse's   splint  may  be  left  off  and  a 

*  The  splint  is  usually  lined  with  lint  \vTung  out  of  the  above  mixture.  But  the 
popliteal  bar  and  any  of  the  splint  close  to  the  wound  must  be  metal  only,  uncovered, 
to  prevent  sepsis.  If  any  spaces  are  found  to  exist  between  the  limb  and  the  splint 
they  may  be  tilled  in  with  cotton-wool,  soaked  in  some  of  the  hot  wax  mixture. 

f  Infrequency  of  dressings  has  been  strongly  insisted  on  by  Prof.  OUier  (^Bev. 
de  Chir.,  Aug.  1887;  Annals  of  Surtferij,  Nov.  1887,  p.  424).  This  most  important 
economy — of  pain  to  the  patient,  and  time  to  the  surgeon — is  only  to  be  secured  by — 
(i)  Eemoving  every  atom  of  the  disease  that  can  be  got  at.  (2)  Providing  drainage. 
The  more  thoroughly  the  disease  is  extirpated,  the  less  need  is  there  to  drain  ;  but 
however  completely  the  disease  is  removed,  many  sutures  should  not  be  employed, 
especially  at  the  ends  of  the  wound.     (3)  Securing  as  dry  a  wound  as  possible. 

%  It  is  especially.  I  think,  from  neglect  of  this  last  detail,  that  the  fact  arises  that 
almost  as  many  cases  are  lost  from  mistakes  in  the  after-treatment  as  from  want  of 
skill  in  the  operation. 


648 


OPERATIONS  ON  THE  LOWER  EXTREMITY. 


leather  splint  fitted  on,  carrying 
flexion.  Some  such  fixed  appar 
three  or  more  years. 

Fig.  264. 


A  case  of  excision  of  both  knees,  two 
years  after  the  operation,  from  a  patient 
under  my  care  at  the  Hospital  for  Chil- 
dren and  Women,  sent  to  me  bj'  Dr.  A. 
T.  F.  Brown,  of  Rocliester.  Botli  knees 
were  the  subject  of  tubercular  disease 
on  admission.  One  was  excised  three 
months  after  the  other. 


years    ago,    and 
mention  here. 


because    it  has 


a  metal  bar  to  resist  the  tendency  to 
atus  should  be  worn,  in  children,  for 

In  early  life  callus-like  material  is 
thrown  out  quickl}^,  and  often  some- 
what irregularly,  between  the  bones, 
but  it  is  extremely  slow  in  really  ossi- 
fying. As  the  quadriceps  extensor 
wastes  much  more  quickly  than  the 
hamstrings,  even  when  the  patella  is 
retained,  the  latter  muscles  keep  up 
their  action  on  the  tibia  for  months, 
and  even  for  years,  until  the  union  is 
firm.  Tenotomy  has  been  advised,  and 
even  resection  of  all  the  hamstring 
tendons  (Dr.  Phelps,  Neiv  York  Med. 
Record,  July  21,  1886;  Annals  of  Sur- 
gery, October  1886,  p.  364).  I  think, 
however,  that  retaining  the  bones  im- 
mobile and  in  good  position,  securing 
early  healing  of  the  wound,  wearing 
a  stiff  apparatus,  and,  wherever  prac- 
ticable, using  the  trans-patellar  method, 
will  best  ensure  a  limb  soundly  anky- 
losed  in  good  position.  A  knee  bent 
later  on  can  be  easily  straightened. 

Causes  of  Failure  and  Death  after 
Excision  of  the  Knee. —  i.  Inveterate 
persistence  of  pulpy  material  leading 
to  (a)  giving  way  of  the  supra-patellar 
pouch,  and  the  results  mentioned  at 
p.  642  ;  (/S)  to  formation  of  caseating 
foci,  especially  at  the  back  of  the  joint 
(p.  643),  and  only  to  be  removed  by 
re-excision  or  amputation.  (2)  An 
unhealthy  condition  of  the  bone  ends, 
with  caries  and  chronic  osteo-myelitis. 
3.  Deficient  reparative  power,  leading 
to  bed-sores,  emaciation,  irritative 
fever,  hectic.  4.  Co-existence  or  sub- 
sequent development  of  such  visceral 
diseases  as  phthisis,  &c.  5.  Surgical 
scarlet  fever.  6.  Septic  Conditions. — 
For  these  the  surgeon  will,  nowadays, 
be,  as  a  rule,  entirely  to  blame. 
7.  Tetanus.  8.  Secondary  Hsemor- 
rhage. — Another  very  rare  condition. 
9.  Fat  Embolism. — This  is  a  still 
rarer  condition,  but  one,  which,  on 
account  of  the  interest  it  excited  some 
once,  at  least,  proved    fatal,   deserves 


ERASIOX   OF  TIIE  KXEE-JOIXT.  649 

The  case  was  that  of  a  child,  aged  12,  submitted  to  excision  for  pulpy  disease  by 
Vogt,  of  Griefswald  (^Cent.  f.  Cltir.,  18S3,  p.  24).  The  bones  were  so  fatty  as  to  cut 
with  a  knife.  Though  but  little  chloroform  had  been  given,  and  the  loss  of  blood  had 
been  slight,  the  patient  died  twenty-four  hours  later  with  shallow  respirations,  feeble 
pulse,  and  low  temperature.  Fat  embolism  of  the  lungs,  extensively  diffused  was 
found  post  mortem.  Yogt  considered  that  this  case  predisposed  to  fat  embolism. 
Thus  cut  vessels  were  exposed  on  the  sawn  surfaces  with  plenty  of  free  oily  matter 
close  by,  and  unable  to  escape,  owing  to  the  bone -ends  being  in  close  contact  (two  wire 
sutures  were  used).  A  similar  case,  after  hip  resection,  by  Prof.  Liicke,  is  mentioned. 
Prof.  Vogt  thought  that  he  would  amputate  in  another  case  if,  after  excision  of  the 
knee,  the  limb  could  not  be  straightened  without  close  apposition  of  the  sawn  fatty 
bone-ends. 

10.  Shock. — This,  though    rare,  must    be    remembered.      Seventeen 
years  ago  I  lost  a  case  from  this  cause. 

The  patient  was  a  delicate  boy,  aged  7.  with  a  large  pulpy  knee.  As  there  was  no 
suppuration,  no  sinuses,  nor  evidence  of  much  mischief  in  the  bones,  I,  unwisely  as  it 
was  proved,  tried  to  save  the  limb.  The  child  sank  a  few  hours  afterwards.  Volkmann 
iCent.f.  Chir.,  Bd.  xii.  Heft  9,  Feb.  28,  1885;  Ann.  of  Surg.,  May  1885,  p.  486)  draws 
attention  to  the  need  of  taking  care  in  children  that  too  much  blood  is  not  lost,  and 
that  deep  narcosis  is  not  too  prolonged. 


ERASION*   OF  THE   KNEE-JOINT. 

Definition. — By  this  operation,  which  we  owe  to  G.  A.  Wright.t  of 
Manchester,  is  meant  a  systematic  removal  of  the  s^movial  membrane, 
which  is,  here,  so  often  pulpy.  If  the  ligaments  are  diseased,  they  are 
also  removed ;  but  if  the  bones  and  cartilage  be  involved,  it  must  be 
only  to  a  slight  degree,  so  that  all  the  disease  can  be  got  away  by  paring 

*  Arthrectomy  was  a  term  introduced  by  Volkmann  (^Cent.f.  Chir.,  1888),  it  is  less 
accurate,  and,  etymologically,  comes  too  near  to  excision. 

t  Lancet,  1881,  vol.  ii.  p.  992;  Med.  Chron.,  July  1885.  See  also  a  paper  by  Mr. 
Shield  QAnn.  of  Surg.,  Feb.  1888).  and  one  by  Mr.  E.  Owen  iMed.-CMr.  Trans.,  vol. 
Ixxii.  p.  56).  The  following  are  Mr.  Wright's  conclusions :  "  In  those  that  have  done 
well  the  common  factors  appear  to  be :  (i)  absence  or  very  small  amount  of  sup- 
puration ;  (2)  superficial  or,  at  least,  not  wide-spread  bone  disease ;  (3)  absence  of 
general  tuberculosis.  In  short,  fairly  early  disease  in  a  not  hopelessly  tuberculous 
child.  This  pretty  well  corresponds  to  the  cases  generally  considered  suitable  for 
excision.  I  have  not  yet  tried  the  operation  in  adults.  It  is  clear  that  extensive 
disease  of  bone  and  much  suppuration  will  not  allow  good  results  to  be  obtained  by 
erasion  ;  neither,  as  a  general  rule,  will  they  by  excision,  though  I  am  quite  sure  that 
the  knee  may  be  successfully  excised  in  cases  where  erasion  is  out  of  the  question,  as 
shown  by  excision  succeeding  where  erasion  has  failed.  Although  in  one  case  a  freely 
movable  joint  resulted,  I  do  not  advise  the  attempt  to  obtain  mobility  by  early  passive 
movement,  except  in  a  few  instances  where  the  wound  has  healed  at  once,  and  there 
is  no  obstacle  in  the  way  such  as  dense  and  lowly  vitalised  cicatricial  tissue.  Erasion, 
if  it  fails,  leaves  the  limb  little,  if  at  all,  in  worse  condition  for  excision  afterwards. 
In  those  cases  where  amputation  became  necessary,  either  the  local  or  constitutional 
condition  forbade  hope  of  successful  excision.  Where  it  succeeds,  erasion  leaves  as 
sound  a  limb  as  excision,  without  shortening.  In  some  cases  there  may  be  mobility, 
though  I  think  in  most  it  will  be  found  that  there  is  not  enough  mobility  to  be  useful ; 
here  the  limb  is  very  liable  to  become  flexed  after  healing  of  the  wound,  but  the  same 
is  true  of  excision  in  children.  I  think,  then,  that  in  suitable  cases  erasion  is,  in 
disease  of  the  knee,  better  surgery  than  excision,  but  its  application  is  strictly  limited. 
In  all  cases  I  have  employed  strictly  Listerian  antiseptics." 


650  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

with  a  knife,  or  scraping  out  with  a  sharp  spoon.  Where  sections  of 
the  bone  have  to  be  made,  the  operation  becomes  an  excision  as  well  as 
an  erasion. 

Value  of  Erasion  as  comixired  icith  Excision ;  Suitable  and  IJnsuitahle 
Cases. — Where  a  knee-joint,  the  site  of  pulpy  trouble,  resists,  in  hospital 
patients,  non-operative  treatment  continued  for  three  or  four  months ; 
where  there  is  no  evidence  of  caseation  in  the  joint  (very  difficult  to 
tell,  but  indicated  by  chronic  obstinacy  of  the  disease,  by  spots  where 
the  feel  is  distinctly  doughy  or  becoming  bluish  in  tint) — in  other 
words,  where  the  disease  is  early,  but,  owing  to  the  patient's  sur- 
roundings, will  go  on  from  bad  to  worse,  erasion  is  preferable  to  excision. 
Its  advantages  are,  (i)  There  is  no  removal  of  bone-slices,  and,  still  less, 
any  interference  with  the  epiphyses.  Thus,  there  is  no  shortening  and 
no  arrest  of  groAvth.  This  latter  advantage  will  be  at  once  recognised, 
when  it  is  remembered  that  (p.  594)  the  increase  in  length  of  the  femur 
takes  place  chiefly  at  the  junction  of  its  shaft  with  the  lower  epiphysis, 
and  in  the  case  of  the  tibia  at  its  upper  epiphysis.  In  one  of  my  cases, 
a  girl  of  II,  there  was  not  onl}^  no  shortening,  but  repeated  careful 
measurements  showed  half  an  inch  increase  of  length,  perhaps  due  to 
the  increase  of  vascularity  after  the  operation,  about  the  above-men- 
tioned epiphyses.  (2)  With  regard  to  the  retention  of  mobility,  the 
frequency  with  which  this  has  been  obtained  and  its  advantage  have 
been,  in  m.j  opinion,  much  exaggerated.  I  have  no  doubt  whatever 
that  a  larger  number  of  carefully  published  cases  will  show  that  where 
movement  is  sought  for,  the  risk  is  run  of  a  certain  degree  of  permanent 
flexion,  of  attacks  of  pain  and  swelling,  and  of  the  formation  of 
troublesome  sinuses.  I  should  strongly  dissuade  from  any  attempt 
to  secure  mobility  in  the  case  of  the  knee  and  ankle.  "  (3)  The 
ligaments  are  less  interfered  with,  and  thus,  the  ties  of  the  joint 
being  preserved,  firm  union  is  more  speedy.  (4)  If  performed  early, 
erasion,  like  excision,  cuts  short  the  disease,  and  thus  gives  a  con- 
siderable saving  of  time  in  children,  at  an  age  when  every  month  is 
of  great  importance.  (5)  It  is  better  suited  to  young  children.  Thus, 
as  it  does  not  arrest  development,  it  may  be  used  very  earl}'.  Wright 
has  operated  "with  perfect  success  in  a  child  under  two  years  of  age."' 

The  disadvantage  of  erasion — I  am  speaking  only  from  an  experience 
of  eighteen  cases — is,  I  think,  chiefly  this,  that  if  the  operation  fail, 
excision  is  rendered  much  more  difficult.  I  cannot  here  at  all  agree 
with  the  statement  of  my  old  friend,  the  chief  authority  on  this  subject, 
that  erasion,  if  it  fail,  leaves  the  limb  little,  if  at  all,  in  worse  condition 
for  excision  afterwards.  This  is  true  of  the  limb,  but  not  of  the  joint. 
In  one  of  m}^  erasions  which  required  excision,  I  found  that  the  pre- 
vious operation  had  entirely  obliterated  the  usual  landmarks,  and  that 
great  difficulty  was  experienced  and  much  care  needed  in  dealing  with 
such  parts  as  the  remains  of  the  posterior  ligament. 

The  cases  suitable  for  erasion  are  those  where  the  disease  is  limited,  or 
almost  limited,  to  the  synovial  membrane,  with  little,  if  any,  caseation ; 
where  the  cartilage  and  bones  are  almost  intact,  where  there  are  no 
abscesses  or  sinuses,  w^here  there  is  no  evidence  of  other  tubercular 
disease,  and  where  the  power  of  repair  is  satisfactory. 

Operation. — The  preliminaries  are  the  same  as  for  excision  (p.  640). 
A  trans-patellar  incision  (Fig.  258,  p.  641)  should  be  employed.     I3ut 


ERASIOX  OF  THE  KNEE-JOINT.  65 1 

to  ensure  thorough  exposure  of  the  supra-patellar  region,  a  very  dan- 
gerous area  on  account  of  its  numerous  nooks  and  crannies  which  give 
lurking-places  to  piilpv  mischief,  I  always  slit  this  pouch  right  up  to 
its  very  top  with  a  sharp-pointed  bistoury,  thus  dividing  the  upper  flap 
into  two.  G.  A.  Wright  ensures  the  same  end  by  making  "  longitudinal 
incisions  through  the  tissues  on  each  side  of  both  halves  of  the  patella, 
iTpwards  as  far  as  the  upper  limit  of  the  synovial  pouch,  and  downwards 
nearly  to  the  tubercle  of  the  patella.'"  The  flaps  being  then,  one  by  one, 
thoroughly  everted  with  a  sharj:)  hook,  taking  the  upper  half  of  the  joint 
first,  I  seize  the  tip  of  one  of  the  flaps  with  mouse-tooth  forceps,  and 
then,  with  blunt-pointed  scissors  curved  on  the  flat,  dissect  the  diseased 
sjmovial  membrane  oflT  the  under  surface  of  the  split  quadriceps  expan- 
sion in  a  continuous  strip  till  the  uppermost  limit  of  the  supra-patellar 
pouch  is  reached.  The  reflection  of  the  synovial  membrane  over  the 
front  of  the  femur  is  then  dealt  with  in  the  same  way,  leaving  the 
periosteum  on  this  c[uite  clean.  The  joint  being  then  well  bent,  and 
the  tibia  being  brought  forward  as  directed  (p.  643,  Fig.  259),  the 
ci'ucial  ligaments,  the  semilunar  cartilages,  the  inter-condyloid  notch, 
and  the  S3movial  reflections  behind  the  crucial  ligaments  are  carefully 
inspected.  To  do  this  thoroughly,  it  is  absolutely  needful  to  divide  the 
lateral  ligaments  sufflcienth'.  With  regard  to  the  other  structures,  some 
retain  the  semilunar  cartilages,  if  healthy,  others  remove  them  in  any  case. 
For  my  part,  as  it  is  so  essential  to  remove  all  the  synovial  membrane, 
and  this  is  impossible  unless  the  semilunar  cartilages  go,  I  always 
remove  them.  With  regard  to  the  crucial  ligaments,  the  anterior  nearlj'- 
always  requires  removal ;  as  regards  the  posterior,  the  whole  ligament, 
or  as  much  of  it  as  possible,  should  be  left,  since  its  removal  is  extremely 
liable  to  be  followed  by  backward  displacement  of  the  tibia.  The  inter- 
condyloid  notch,  and  the  reflection  behind  the  crucial  ligaments,  is  then 
taken  in  hand,  very  wide  flexion  of  the  joint,  and  a  finger  of  an  assistant 
in  the  popliteal  space,  here  facilitating  this,  the  most  difficult  and 
important  j^art  of  the  operation.  When  much  disease  is  present  here  in 
the  sj^novial  membrane,  both  crucial  ligaments  must  be  unhesitatingly 
diA'ided,  and,  if  needful,  the  overhanging  posterior  part  of  the  condyles 
must  be  cut  awa}'.  In  dealing  with  the  synovial  membrane  in  the  inter- 
condyloid  notch,  the  surgeon  must  remember  that  he  will  never  have  a 
similar  chance  of  dealing  with  the  disease  here,  and  that,  if  anj^  is  left 
behind,  excision,  and  perhaps  amputation,  will  be  called  for.  The 
synovial  membrane  around  the  lower  half  of  the  patella  is  then  removed, 
and  finally  the  ends  of  the  bones  are  examined.  Any  pits  and  foci  are 
gouged  out,  and  more  extensive  ulceration  shaved  oft'  with  a  strong- 
sharp  knife.  Drainage,  if  needful  (p.  646),  is  then  provided  by  making 
counter-punctures  with  a  Lister's  sinus-forceps  in  the  popliteal  space, 
on  each  side  of  the  limb.  The  dressings  are  applied  with  the  same  pre- 
cautions given  at  p.  647,  and  not  until  all  is  completed  is  the  Esmarch's 
bandage  removed.  Throughout  the  operation  irrigation  with  lot.  hydr. 
perch.,  I  in  3000,  should  be  diligently  employed. 

The  after-treatment  is  the  same  as  after  excision  (p.  647),  as  there  is 
the  same  tendency  for  a  long  while  for  the  limb  to  become  flexed,  there 
is  the  same  urgent  need  for  a  rigid  apparatus  for  several  years. 

Causes  of  Failure  after  Erasion. — These  are  chiefly:  (i)  Some  of  the 
disease  is  left  behind.     This  is  known  by  a  persistent  sinus,  and  the 


652  OPEKATIOXS  ON  THE  LOWER  EXTEEMITY. 

liability  of  the  limb  to  become  puffy,  hot,  and  tender.  (2)  Inability  of 
the  patient  to  repair  the  wound  ■which  is  left.  (3)  Failure  of  the 
surgeon  to  maintain  asej)sis. 


WIRING  FRACTURES  OF  PATELLA. 

This  operation,  brought  before  the  profession  by  Lord  Lister  in  1883, 
seems  to  have  dropped  somewhat  out  of  notice.  This  is  chiefly  due  to  two 
facts :  {a)  Many  surgeons  consider  that  the  results  of  non- operative 
treatment  are  satisfactory.  Dr.  Powers  (Ann.  of  Surg.,  July  1898,  p.  6y) 
records  the  opinions  of  ninety  surgeons  on  the  subject.  Seventeen  of 
these,  or  over  23  per  cent.,  are  deliberately  opposed  to  the  operation, 
nine  urge  operation  in  all  cases,  while  forty-one,  or  over  56  j^er  cent., 
recommend  operation  only  in  certain  cases.  (J))  In  spite  of  the  vastly- 
increased  familiarity  with  antiseptic  methods,  much  of  the  old  dread  of 
opening  the  knee-joint  still  survives.  And  there  is  no  doubt  that  infec- 
tion of  the  joint  does  occur  occasionally  even  in  the  hands  of  well-known 
careful  surgeons.  In  a  total  of  711  operation  cases  collected  by  Dr. 
Powers  (loc.  supra  cit.)  there  were  three  deaths  from  sepsis,  and  probably 
there  were  other  cases  in  which  suppuration  occurred,  for  in  the  total  of 
711  cases  there  were  two  in  which  total  ankylosis  took  place,  and 
twenty-eight  others  in  which  "  marked  stiffness  and  disability  "  resulted. 
Although  these  cases  form  a  comparatively  small  proportion,  neverthe- 
less they  have  to  be  reckoned  with  when  putting  the  question  of 
operation  before  the  patient  and  his  friends,  and  have  to  be  balanced 
against  the  longer  period  of  treatment  necessary,  and  the  disability  due 
to  bad  union  if  non-operative  treatment  is  carried  out. 

In  the  remaining  671  cases  collected  by  Dr.  Powers,  or  in  94  per 
cent.,  the  result  was  "  satisfactory,"  so  that  the  operation  may  be  con- 
sidered to  be  fully  justified  under  certain  conditions.  The  indications 
may  be  stated  thus  : — 

1.  In  Lord  Lister's  words  (loc.  sityra  cit.),  "no  man  is  justified  in 
performing  such  an  operation,  unless  he  can  say  with  a  clear  conscience 
that  he  considers  himself  morally  certain  of  avoiding  the  entrance  of  any 
septic  mischief  into  the  wound." 

2.  Certain  Cases  of  Old  Fracture  of  the  Patella. — -This  important 
matter  must  be  taken  somewhat  in  detail.  The  chief  points  here 
justifying  resort  to  wiring  are :  (a)  Failure  of  previous  treatment,  espe- 
cially in  hospital  patients,  (b)  A  useless  limb,  especially  in  a  man  \\hose 
occupation  entails  much  walking  or  standing,  where  the  gait  is  helpless 
and  requires  much  attention,  or  where  many  falls  have  followed  involv- 
ing serious  risk  of  fracture  on  the  opposite  side.  (c)  Where  both 
patellas  are  fractured.  (J)  Where  the  patient  is  young  and  has  man}" 
years  of  active  life  before  him.  (e)  Where,  if  not  young,  the  patient  is 
sufficiently  healthy,  (j)  Where  enough  is  known  of  the  patient's  habits 
to  ensure  his  being  amenable. 

3.  Recent  Fractures. — These  must  be  considered  separately,  according 
as  they  are  (a)  simple ;  or  (/>)  compound.  In  the  former  case  the 
general  opinion  of  the  profession  has  appeared  to  be  against  operation, 
owing    to    the    good    result    which    usuall}^   follows    on   non-operative 


WIRING  FRACTURES  OF  PATELLA.  653 

measures.  Lord  Lister's  *  five  cases  of  wiring  in  recent  fractures  prove 
how  safe  this  method  is  in  skilled  hands,  (b)  In  compound  fractures 
the  matter  seems  to  me  to  be  different.  Here  a  wound  already  exists, 
and,  if  the  patient's  condition  is  good,  no  harm  can  be  done  by  wiring, 
with  antiseptic  precautions,  any  fragments  which  happen  to  be  widely 
separated.  Furthermore,  such  a  step  may  be  easily  combined  with  the 
needful  examination  and  irrigation  of  the  joint  with  dilute  solution  of 
mercury  perchloride  or  carbolic  acid.f 

Operation. — The  parts  being  thoroughly  cleansed,  an  incision  is 
made,  with  the  strictest  antiseptic  precautions,  about  three  and  a  half 
inches  long,  either  vertically  or  transversely.  The  former  is  adopted  by 
Lord  Lister.  The  latter  is  more  convenient,  and  admits  more  readily 
of  getting  at  the  lateral  aspects  of  the  joint,  if  the  aponeurosis  above 
requires  division  at  these  points. |  It  is  said  to  have  the  disadvantage 
of  being  more  likely  to  give  way  and  expose  the  joint  if  a  refracture 
should  take  place  later.  I  used  it  in  four  out  of  the  five  cases  men- 
tioned below,  and  think  it  well  to  make  it  rather  above  or  below  the 
interval  between  the  fragments,  so  that  this  and  the  wound  shall  not 
lie  opposite  to  each  other. §  The  fragments  when  exposed  ||  are  generally 
found  embedded  in  fibrous  tissue,  thickened  synovial  membrane,  and 
old  decolorised  coagulum.  This  must  be  snipped  or  cut  away,  and  any 
spirting  vessels  in  the  thickened  synovial  membrane  must  be  secured. 
In  old  cases  a  very  thin  section  from  each  fragment  is  then  removed 
with  a  narrow-bladed  saw,  this  needing  miich  caiition  in  the  case  of  the 
lower  one,  w^hich  is  the  smaller  of  the  two.  If  the  fragments  can  now 
be  pressed  into  close  apposition,  nothing  remains  save  to  wire  them,  but 
the  case  is  by  no  means  so  simple  where  the  bones  are  widely  apart. 

Thus,  in  oue  of  my  cases,  after  paring  the  fragments — tliese  were  quite  two  and  a  half 
inches  from  each  other — and  after  most  forcible  traction  the  upper  could  only  be  made 
to  descend  three-quarters  of  an  inch.  Malgaigne's  hooks  were  applied  and  tightly 
screwed  up,  but  with  no  result  on  the  desired  approximation.  The  lateral  expansions 
of  the  quadriceps  were  next  still  more  fully  divided  (cut  muscular  fibres  being  seen  on 
the  inner  side),  but  the  fragments  were  almost  as  far  apart  as  ever.  As  the  only 
alternative  to  excising  the  joint  (in  order  to  substitute  a  firm  support  for  the  flail-like 
limb),  I  now  divided  partially  the  rectus  tendon,  but  it  was  not  till  the  upper  frag- 
ment was  only  held  by  a  narrow  stout  band  at  its  upper  and  inner  parts  that  it  could 
be  brought  in  apposition  with  the  lower  one.     The  res^^lt  was  excellent. 


*  Lord  Lister  goes  so  far  as  to  consider  (^Lancet,  Nov.  3.  1883)  that  "the  ununited 
case  is  in  every  respect  worse  as  a  subject  of  operation  than  the  recent."  This  is 
chiefly  owing  to  the  wasting  of  the  fragments  and  their  greater  separation.  Again, 
in  recent  cases,  there  is  no  need  to  pare  the  fragments,  for  after  sponging  away 
of  clots  the  surfaces  are  ready  for  coaptation. 

t  Dr.  G.  R.  Fowler,  of  New  York  (Jw«.  of  Surg.  Sept.  1885,  p.  248),  calls  attention 
to  the  great  importance  of  making  these  cases  aseptic  at  the  first.  In  his  case  the 
bone  was  split  up  into  three  fragments.  The  two  lower  ones  were  first  wired  together, 
and  their  upper  margins  were  next  sutured  to  the  upper  fragment  by  two  wire  sutures, 
one  for  each  lower  fragment. 

+  It  would  also  be  probably  more  convenient  in  a  compound  fracture. 

§  An  Esmarch's  bandage  is  not  needed,  and  would  have  the  objections  of  causing 
oozing  afterwards  into  the  joint-cavity,  and  also  of  preventing  that  bringing  down  of 
the  extensors  of  the  thigh  which  may  be  required  in  cases  of  wide  separation. 

II  In  one  case,  the  skin  being  dimpled,  puckered  down,  ami  adherent  between  the 
fragments,  I  had  to  cut  away  a  piece  about  three-quarters  of  an  inch  wide. 


654  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

In  these  difficult  cases  it  must  be  remembered  that  it  is  not  abso- 
lutely necessary  to  get  the  fragments  into  exact  apposition.  If,  after 
wiring,  they  come  within  a  quarter  of  an  inch  of  each  other,  the  limb 
will  be  a  most  useful  one,  though  of  course  exact  apposition  is  to 
be  desired.*  When,  in  spite  of  all  the  above,  approximation  of  the 
fragments  is  still  impossible — though  it  is  difficult  to  imagine  such  a 
contingency — the  knee  should  be  excised  either  now  or  on  another 
occasion,  so  as  to  give  a  firm  support. 

The  fragments  being  sufficiently  approximated,  they  are  now  drilled. 
This  may  be  easily  effected  by  an  ordinary  bradawl,  sterilised.  The 
bones  should  be  drilled  obliquely,  the  instrument  entering  each  frag- 
ment a  full  half  inch  from  the  fracture  on  the  upper  surface,  and 
emerging  above  the  cartilaginous  surface  below. f  Where  the  lower 
fragment  is  -too  small  to  hold  a  wire,  this  may  be  passed  through  the 
ligamentum  patellae,  as  has  been  done  by  Lord  Lister  (loc.  supra  cit.) 
and  Mr.  Teale  (Brit.  Med.  Joiirn.,  June  9,  1883).  One  wire  would 
appear  to  be  sufficient :  though  this  unites  the  centre  of  the  fragments 
exactly,  a  very  slight  interval  remains  at  the  edges,  but  does  not  inter- 
fere with  an  excellent  result. 

When  the  wire  is  twisted,  two  half-twists,  or  one  complete  one,  will 
be  sufficient,  and  it  should  be  noted  at  the  time  in  which  direction 
the  twist  is  made,  in  case  the  wire  is  removed.  This  raises  the 
question  as  to  the  best  way  of  dealing  with  the  wire,  whether  to  cut 
it  short  and  embed  the  ends  by  gently  hammering  them  into  the  fibrous 
tissue  over  the  upper  fragment,  or  to  leave  the  wire  long  enough  to 
admit  of  its  being  removed  later.  I  have  alluded  to  this  question  at 
p.  631.  Lord  Lister  advocates  the  former  course.  I  shall  not,  I  trust, 
be  thought  wanting  in  proper  respect  if  I  suggest  that  in  the  knee,  at 
least  in  women  who  have  much  kneeling,  removal  of  the  wire  will  be 
more  satisfactory.  Thus,  in  one  of  my  cases,  in  which  I  had  ham- 
mered down  the  wire,  the  woman  returned,  nearly  a  year  later,  to  have 
the  wire  removed.  She  liad  not  been  able  to  kneel,  the  suture  could  be 
felt,  and  at  one  spot  the  skin  was  ulcerating  over  it.  I  ought  to  state 
that  the  patient  was  a  very  thin  one,  and  that  I  had  made  three  or  four 
half-twists  instead  of  two.  t 

*  In  a  case  of  Mr.  Wheelhouse's  (Brit.  Med.  Joiirn.,  June  9,  1883)  the  fragments, 
originally  an  inch  and  a  half  ajiart,  could  only  be  brought  within  half  an  inch  of  each 
other  ;  an  excellent  limb  resulted. 

t  While  it  is  well  to  take  this  last  precaution,  it  probably  does  not  matter  much 
(supposing,  of  course,  that  strict  antiseptic  precautions  are  taken)  if  the  wire  is 
passed  within  the  joint.  Lord  Lister  gives  the  following  aid  to  making  the  two  drill- 
holes exactly  correspond  :  "  Supposing  that  on  one  side  the  instrument  should  have  come 
too  far  down,  it  may  be  into  the  cartilage,  we  do  not  regard  that  at  first,  but  pass  the 
wire  through  the  two  driU-holes,  and  then  on  that  side  on  which  the  hole  has  come  too 
far  down,  by  means  of  the  bradawl  we  simply  chip  away  a  little  of  the  material  that 
is  above  the  wire,  until  the  wire  comes  to  be  in  a  position  exactly  opposite  to  the  hole 
on  the  other  side."  If,  in  another  case,  there  is  a  difficulty  in  making  the  drill  emerge 
upon  the  fractured  surface,  Lord  Lister  would  advise  the  withdrawal  of  the  drill  and 
substitution  of  the  blunt  end  of  a  needle,  and  then  with  a  gouge  or  bradawl  an  opening 
is  excavated  upon  the  fractured  surface,  opposite  to  the  other  drill-hole,  until  the 
needle  is  exposed ;  the  wire  can  then  be  easily  passed. 

X  Prof.  Macewen  (loc.  infra  cit.')  mentions  a  case  which  came  under  observation 
three  months  after  suture  of  the  patella,  with  acute  suppurative  arthritis  of  the  joint 


I 


WIRING  FRACTUKES  OF  PATELLA.  655 

Before  the  wire  is  twisted  or  hainiiiered  down,  if  this  course  is  decided 
upon,  the  surgeon  must  decide  as  to  drainage  of  the  joint.  When  the 
operation  has  been  difficult,  involving  much  separation  of  adhesions  and 
interference  with  the  parts,  drainage  should  be  employed  through  the 
wound  to  the  most  dependent  part  of  the  joint  at  the  outer  side  (Lister), 
thrusting  the  instrument  here  through  the  joint  and  soft  parts,  cutting 
upon  it  and  di'awing  a  drain  through.  The  wound  is  then  united  and 
dressed.  As  soon  as  the  deeper  part  of  the  wound  is  healed,  every 
pains  must  be  taken,  by  massage,  &c.,  to  improve  the  atrophy  of  the 
quadriceps.  Healing  should  be  complete  in  three  weeks.  If  it  be 
decided  to  remove  the  wire,  this  may  be  done  six  or  eight  weeks  after 
the  operation,  by  making  a  small  incision  through  the  scar.  The 
number  of  half-twists  and  the  direction  in  which  they  have  been  made 
must  be  recollected  at  this  time.  The  wire  is  first  untwisted  and 
straightened,  one  is  next  cut  off  short,  and  the  other  grasped  in 
dressing-forceps,  and  wound  round  the  tips  of  these.  It  is  then 
extracted  without  jerking. 

The  question  of  passive  movement  now  arises.  Usually,  about  six 
or  eight  Aveeks  after  the  operation,  the  patient  may  get  up  and  begin  to 
use  the  limb  (with  the  aid  of  two  sticks  at  first),  flexion  and  extension 
being  diligently  practised.  Unless  the  joint  is  xevj  stifi",  massage, 
friction,  and  gentle  persevering  movement,  aided  by  time  and  patience, 
will  be  sufiicient.  If  an  ana?sthetic  is  given,  movements  must  be  made 
cautiously,  as  the  patella  has  been  refractured  on  this  occasion  more 
than  once.* 

Dif3.culties  in  Wiring  the  Patella. 

I.  Atrophied  surfaces  of  the  fragments,  making  it  difficult  to  refresh 
them  satisfactorily.  2.  A  very  small  lower  fragment.  3.  Fragments 
embedded  in  very  firm  fibrous  tissue,  fascial,  periosteal,  and  synovial,  or 
old  coagulum.  This  condition  will  prevent  satisfactory  apposition  iinless 
the  intervening  tissue  be  all  removed.  In  a  very  interesting  case 
recorded  by  Mr.  0.  Ward  (Lancet,  Nov.  i,  1S84)  it  was  found,  on 
exploring  the  fragments,  that  the  capsular  tissues  torn  off"  the  lower 
fragment  remained  attached  above,  and  hung  like  a  flap  between  the 
fractured  surfaces,  effectually  preventing  their  apposition.  It  is 
suggested  that  some  such  complication  may,  in  man}-  cases  which  have 
been  treated  in  the  usual  way,  cause  the  fragments  to  fall  apart  as  time 


and  ulceration  of  the  cartilage.  A  probe  passed  through  a  sinus  detected  the  wire 
surrounded  bv  carious  bone.  The  twist  was  still  intact,  but  the  loop  was  loose,  the 
bone  having  become  inflamed,  softened,  and  ulcerated.  Excision  of  the  joint  was 
required.  This  shows  that,  occasionally,  the  wire  may  excite  irritation,  and  thus  lead 
to  serious  results.  Mr.  Turner  (^Lancet,  1887,  vol.  i.  p.  572)  records  a  case  in  which 
Mr.  M.  Eobson.  of  Leeds,  had  wired  an  ununited  fracture  of  the  patella,  three  gold  wires 
being  employed.  The  patient,  an  epileptic,  probably  injured  the  knee  repeatedly,  the 
wires  worked  out,  and  the  knee-joint  became  acutely  inflamed,  requiring  free  incisions 
and  drainage. 

*  In  one  of  Lord  Listers  cases  (loc.  supra  cit.'),  passive  movement  being  employed 
with  ••  considerable  force "  four  weeks  after  the  wiring,  the  rigid  quadriceps  not 
yielding,  the  wire  gave  way,  and  the  cicatrix  (a  long  longitudinal  one),  which  had 
healed  save  where  the  wire  projected,  opened.  The  joint  was  at  once  washed  out 
antiseptically,  and,  six  days  later,  some  coagula  were  removed  and  the  old  wire 
re-twisted.     An  excellent  limb  was  the  result. 


656  OPEEATIOXS  OX  THE  LOWER  EXTREMITY. 

goes  on.  This  is  supported  by  Prof.  Macewen  {Lancet,  Nov.  17,  1883  ; 
Ann.  of  Surg.,  March  1887,  p.  178),  who  has  collected  thirteen  cases  of 
transverse  fracture  of  the  patella,  in  which  portions  of  soft  tissue  inter- 
vened between  the  fragments  in  such  a  manner  as  to  render  osseous 
union  an  impossibility.  4.  A  contracted,  rigid  quadriceps.  5.  In- 
dipping  skin.  p.  653.  6.  Multiple  fragments. — This  may  cause  much 
difficulty,  especially  if  it  is  the  lower  and  usually  smaller  fragment 
which  is  comminuted.  If  the  lower  fragment  is  large  enough  to  bear 
wiring,  a  smaller  one  may  be  removed ;  or  the  wire  may  be  passed 
through  the  ligamentum  patellae.  If  a  case  seemed  to  require  it  I 
should  not  hesitate  to  wire  smaller  fragments  with  finer  wire,  and  to 
pass  one  stout  one  from  the  highest  to  the  lowest  fragment  (or  liga- 
mentum patellse).  this  wire  lying  in  the  joint,  and  passing  under  and 
over  one  of  the  smaller  ones.  To  give  a  firm  support  excision  could  be 
resorted  to  as  a  last  resort,  either  at  the  time  or  later. 

Causes  of  Failure. — These  are,  mainly :  i .  Inability  to  bring  the 
fragments  together. — Mr.  Turner  (Clin.  Soc.  Trans.,  vol.  xviii.  p.  41) 
mentions  a  case  in  which  the  operation  was  abandoned,  as  it  was  found 
impossible  to  get  the  fragments  together  after  wiring  them.  The 
patient  was  "'  no  better  and  no  worse  "  eventually.  2.  Septic  conditions. 
3.  Necrosis  of  a  fragment. — This  is  a  complication  rather  than  a  cause 
of  failure.  It  is  especially  likely  to  occur  after  severe  compound 
fractures,  in  which  the  periosteum  was  much  injured  at  the  time  of  the 
accident.  This  happened  with  the  upper  fragment  in  Dr.  Ct.  E. 
Fowler's  case  already  quoted.  About  three  months  after  the  wiring, 
this  fragment,  about  the  size  of  a  walnut,  was  removed.  It  was  now 
found  that  "  the  joint  was  perfectly  closed  b}^  a  thick  fibrous  capsule 
underlying  the  necrosed  portion,  connected  to  the  upper  margins  of  the 
now  firmly  united  two  lower  fragments,  and  forming  a  strong  bond  of 
union  between  the  quadriceps  above  and  what  remained  of  the  patella 
below."  The  resulting  limb  was  useful,  with  considerable  movement  at 
the  knee-joint. 


REMOVAL     OF    LOOSE     BODIES*    FROM    THE    KNEE-JOINT. 

This  is  another  instance  of  an  operation  rendered  safe  and  simple  by 
the  antiseptic  treatment  of  Lord  Lister.  Removal  by  direct  incision 
will  therefore  be  alone  described  here. 

*  The  following  classification  may  be  iiseful  to  a  surgeon  about  to  operate  for  one 
of  these  bodies :  (i)  A  thickened  or  indurated  synovial  fringe  which  has  become 
pedunculated  and  perhaps  detached  ;  (2)  a  fibro-enchondroma  originating  in  those 
cartilage  cells  which  are  naturally  found  in  the  synovial  fringes  ;  (3)  a  portion  of 
articular  cartilage  detached  by  injury  (four  years  ago  I  removed  one  of  these  loose 
bodies  from  the  knee-joint  of  a  railway  porter  who  came  to  me  for  synovitis,  with  the 
history  that  the  attacks  dated  from  the  time  when  a  cask  which  he  was  moving  had 
slipped  and  struck  the  inner  side  of  his  right  knee-joint — Lancet,  i88g,  vol.  ii.  p.  .363)  ; 
(4)  a  bit  of  cartilage  may,  after  injury,  gradually  become  detached  by  a  process  of 
quiet  necrosis  (Paget)  ;  (5)  blood  effused  into  a  synovial  fringe  ;  (6)  mass  of  fibrine  ; 
(7)  a  detached  osteophyte  ;  (8)  Mr.  H.  Marsh  QDis.  of  Joints,  p.  182)  mentions  a  case 
of  Mr.  Shaw's,  in  which  a  loose  body  on  removal  was  found  to  contain  the  point  of  a 
needle. 


INTERNAL  DERANGEMENTS  OF  THE  KNEE.  657 

Operation. — The  parts  having  been  kept  at  rest  for  some  days 
before  and  scrupulously  cleansed,  the  foreign  body  is  found,*  if  possible, 
and  retained  in  a  superficial  part  of  the  capsule.  If  it  be  very  movable, 
it  should  be  harpooned  with  a  sterilised  needle  at  the  beginning  of  the 
operation.  The  joint  is  then  deliberately  and  sufficiently  opened.  In 
the  traumatic  case  I  have  mentioned,  the  body  could  not  be  felt  at  the 
time  of  the  operation ;  on  cutting  freely  into  the  joint  I  came  down  on 
a  tiny  pedunculated  body  attached  to  the  deformed  internal  condyle ;  as 
this  was  evidently  too  small  to  be  the  offending  body,  I  had,  after 
removing  it,  to  make  a  prolonged  search  with  the  finger  before  the  loose 
cartilage  was  found  at  the  extreme  upper  end  of  the  supra-patellar  pouch. 
In  any  such  case  where  the  body  can  be  felt,  but  not  brought  down,  a  second 
incision  should  be  made  over  it.  All  bleeding  is  now  finally  arrested, 
and  the  woiTnd  closed  by  two  layers  of  sutures,  of  which  the  deeper 
takes  up  the  capsule.  If  the  operation  has  been  a  simple  one,  no  drain- 
age will  be  required,  effusion  being  prevented  by  aseptic  precautions 
and  firm,  even  bandaging.  Where  the  search  has  been  prolonged,  the 
parts  much  interfered  with,  or  many  bodies  removed,  a  horsehair  drain 
or  a  small  tube  must  be  passed  through  the  wound  and  a  counter- 
puncture  made  at  the  most  dependent  part  of  the  joint. 

Iodoform  having  been  dusted  on,  the  usual  dressings  are  applied,  and 
the  limb  put  up  on  a  back  splint. 


INTERNAL    DERANGEMENTS    OF    THE    KNEE. 
SLIPPED    FIBRO-CARTILAGE.t 

These  affections  are  so  crippling  and  vexatious  that  I  shall  allude  to 
them  here,  though  operative  interference  will  be  rarely  required  if  the 
case  is  treated  by  the  proper  apparatus  (vide  i/}fra).  The  key-note 
to  the  satisfactory  recognition  of  these  injuries  and  their  well-doing  is 
a  recognition  of  the  fact  that  one  of  the  semilunar  cartilages,  usually 
the  internal,  may  after  a  hurt  or  wrench  of  the  joint  be  partially  torn 
away  from  its  marginal  attachments,  usually  the  anterior  ones 
(Annandale).  In  some  cases  the  cartilage  is  split  instead  of  displaced ; 
in  others  it  undergoes  gradual  enlargement  in  consequence  of  repeated 
injury  and  synovial  irritation.  With  regard  to  treatment,  it  should  be 
distinctly  understood  that,  after  reduction,  rest,  counter-irritation,  &c., 
the  application  of  ordinary  splints  or  knee-caps  is  not  of  the  very 
slightest  use ;  there  is  one  instrument,  and,  as  far  as  I  know,  one  only, 
which  will  meet  these  cases,  and  do  away  in  the  great  majority  of  them 

*  The  patient  is  often  clever  at  this.  Mr.  H.  Marsh  Qloc.  supra  cit.')  suggests  that  it 
maj'  save  disappointment  if  fixing  the  body  has  been  practised  beforehand  by  the 
assistant  to  whom  this  oflBce  is  to  be  entrusted.  In  those  rare  cases  where  the  body 
cannot  be  found,  no  surgeon  familiar  with  antiseptic  details  would  hesitate  to  freely 
cut  into  the  joint  if  the  history  and  the  crippling  of  the  patient  justified  this.  In 
other  cases,  as  occasionally  happens  in  lithotomy,  the  body  is  known  to  be  present,  but 
cannot  be  felt  when  the  patient  is  on  the  table. 

t  Reference  should  be  made  on  this  subject  to  the  following  writings : — Hey,  Praci. 
Ohserv.  in  Sitrtf.,  1803;  Howard  Marsh,  Bis.  of  the  Joints,  p.  190;  Annandale,  5n7, 
Med.  Journ.,  1887.  vol.  i.  p.  319;  H.  W.  Allingham,  ibid.,  1888,  vol.  i.  p.  iiio,  and 
Treatment  of  Internal  Derangements  of  Knee- Joint  by  Operatitm. 

VOL.   II.  42 


658  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

with  any  need  of  operation,  and  that  is  the  ''  knee-clamp '"  made  by 
Spratt,  Hawksley,  &c.,  and  figured  b}^  Mr.  H.  Marsh  in  his  excellent 
account  of  this  affection  (Dis.  of  the  Joints,  pp.  212,  213).  Having- 
watched  the  use  of  these  clamps  in  many  patients,  I  can  testify  most 
strongly  to  their  value. 

Operation. — Where  the  above  clamps  fail,  or  where  other  trouble  is 
present,  as  in  Prof.  Annandale's  and  my  cases  ;  where  the  life  is  spoilt 
b}-  the  affection,  and  other  conditions  are  satisfactory,  opening  the  joint 
and  removal  or,  much  more  rarely,  suture  of  the  cartilage  is  justifiable. 
The  skin  having  been  carefully  cleansed,  and  the  strictest  antiseptic 
precautions  made  use  of,  an  incision,  longitudinal  as  in  the  case  men- 
tioned below — a  transverse  gives  more  room  but,  I  think,  weakens  the 
joint  more — is  made  over  the  fibro-cartilage,  for  about  three  inches. 
All  bleeding  having  been  carefully  arrested,  the  synovial  membrane  is 
incised,  and  hjemorrhage  again  stoj^ped.  The  condition  of  the  cartilage 
is  then  investigated,  and,  if  displaced,  it  is  drawn  into  position  with  a 
blunt  hook,  and  removed  or  sutured*  with  fine  silk  to  the  periosteum 
and  fascia  over  the  edge  of  the  head  of  the  tibia.  If  the  cartilage  cannot 
be  thus  brought  into  position,  it  should  be  removed,  and  the  same 
should  be  done  if  a  portion  is  found  split  off  but  still  attached.  Any 
growth  that  is  present,  whether  fibro-fatty  of  the  synovial  membrane.f 
or  an  osteo-arthritic  outgrowth  from  the  bone  (vide  infra),  should  be 
removed  by  scissors,  saw,  &c.  If  drainage  is  considered  necessary,  a 
few  strands  of  horsehair  are  inserted,  and  the  synovial  membrane  then 
carefully  brought  together  vcith  buried  sutures  of  fine  silk.  The  skin 
incision  is  then  closed  with  sutures.  In  about  three  weeks  careful 
movements  of  the  joint  should  be  begun.  The  chief  trouble  in  the 
after-treatment  is  obstinate  stiffness,  which  is,  however,  usually  over- 
come in   course  of  time. 

The  following  are  brief  notes  of  one  of  the  few  cases  in  which  I  have 
found  it  needful  to  remove  a  semilunar  fibro-cartilage.  It  will  be 
noticed  that  previous  treatment  had  failed,  and  that  osteo-arthritis  was 
present  to  a  marked  degree  in  a  young  patient  : — 

R.  C,  aged  35.  had  had  repeated  displacement  of  his  left  fibro-cartilage  since  a 
wrench  of  his  kuee  when  17  rears  old.  A  clamp  gave  great  relief  for  some  time,  but 
latterly  this  ceased  to  be  any  safeguard.  In  April  1894,  I  opened  the  knee-joint  by  a 
vertical  incision  three  inches  long,  placed  about  an  inch  from  the  inner  margin  of  the 
patella,  and  beginning  opposite  its  centre.  The  first  thing  to  come  into  view  when  the 
joint  was  opened  was  the  inner  condyle  with  its  margin  converted  into  a  huge  lip, 
everted  and  raised  and  covered  with  a  network  of  many  minute  vessels.  The  head  of 
the  tibia,  as  far  as  seen,  presented  the  same  appearance  along  its  articular  rim.  The 
internal  fibro-cartilage  was  found  detached  from  its  connections   to  the   tibia   and 


*  This  step  can  rarely  be  advisable.  It  is  difficult  to  get  a  secure  hold  for  the 
sutures.  Mr.  M.  Moullin  ^Lancet,  1895,  "^ol-  i-  P-  1233)  mentions  two  cases  in  which 
the  displacement  recurred  after  suture.  In  his  words  :  '•  Sutures  and  adhesions  cannot 
make  it  stronger  than  it  was  before  it  was  hurt,  unless  they  fit  it  so  that  it  is  com- 
pletely rigid ;  and  if  it  gave  way  before,  it  will  give  way  all  the  more  easily  a  second 
time  if  exposed  to  a  similar  strain." 

t  In  very  rare  cases,  with  the  history  and  symptoms  of  displaced  fibro-cartilage, 
the  menisci  are  found  in  situ,  and  the  only  abnormality  and  cause  of  interference  with 
the  movements  of  the  joint  is  a  small  mass  of  fibro-fatty  tissue  lying  over  the  fibro- 
cartilage  at  the  site  of  pain  (Annandale,  Brit.  Med.  Jouni.,  1887,  vol.  i.  p.  320). 


INTERNAL  DERANGEMENTS  OF  THE  IvNEE.  659 

carried  up  \vith  the  femur.  It  was  thin,  flaccid,  and  limp,  flattened  out,  its  circum- 
ferential border  having  lost  its  thickness  and  convexity.  No  bleeding  followed  on 
snipping  through  its  posterior  attachments.  The  "lipping"  of  the  cartilage  on  the 
femur  and  tibia  was  rounded  ofl:  with  a  metacarpal  saw,  some  sessile  growths  of  the 
.-■yuovial  membrane  were  snipped  away,  and  two  small  osteophytes  removed  from  the 
articular  surface  of  the  patella.  The  inner  aspect  of  the  joint  was  carefully  dried  out 
with  aseptic  sponges,  and,  as  much  oozing  was  expected  from  the  sawn  surfaces,  a 
drainage-tube  was  passed  into  the  upper  cul-de-sac  and  brought  out  through  the 
wound.  The  wound  healed  quickly ;  a  month  later  the  patient  could  walk  across  Hyde 
Park,  but  it  was  not  till  nearly  six  months  after  the  operation  that  flexion  and 
extension  were  completely  restored,  and  the  patient  could  say  that  there  was  "  not 
much  to  choose  between  the  two  knees."  I  saw  him  two  years  after  the  operation  ; 
he  could  then  use  the  lower  limbs  with  equal  freedom,  and  the  movements  of  the  left 
knee  were  quite  smooth.     He  was  able  to  walk,  ride,  and  shoot  with  entire  comfort. 

Another  case  which  had  J^eeu  watched  after  the  operation,  before 
being  reported,  was  brought  by  Mr.  Lockwood  before  the  Clinical 
Society  {Trans.,  vol.  xxvii.  p.  133;  Lancet,  1894,  vol.  i.  p.  673).  Here 
twenty-one  months  had  elapsed  since  the  operation.  The  left  knee  had, 
after  an  injury,  l^een  liable  to  become  locked  under  circumstances 
which  rendered  the  patient's  occupation,  that  of  an  engineer,  dangerous. 
Though  nothing  could  be  felt  externally,  when  the  joint  was  opened  the 
internal  fibro-cartilage  was  found  to  have  its  anterior  third  torn  up  from 
the  tibia.  This  portion  was  cut  away,  and  the  remainder  sewni  down  to 
the  tibia  with  silk  sutures.  The  patient  made  a  rapid  recovery,  but 
neglecting  the  advice  given,  not  to  play  tennis  or  football  for  a  year, 
liad  synovitis  with  considerable  effusion  after  taking  violent  exercise. 
Later  on,  he  reported  that  for  walking,  riding,  and  swimming  the  knee 
was  as  good  as  the  other.  Exercises  involving  any  risk  of  twisting  the 
joint  he  had  avoided. 

The  following  case  operated  upon  by  one  of  us — F.  J.  Steward — 
also  well  illustrates  the  benefit  of  operation  in  certain  severe  cases  ; 

The  patient — a  student — had  suffered  for  over  seven  years  from  repeated  dis- 
placement, latterly  brought  about  by  quite  trivial  movements,  such  as  stepping  off 
a  kerb.  The  operation  was  performed  in  August,  1900;  the  cartilage,  which  had 
been  completely  torn  from  its  anterior  attachments,  being  removed.  At  the  present 
time,  January,  1902,  the  patient  is  playing  football  regularly,  and  does  not  notice 
the  slightest  difference  between  his  two  knees. 


CHAPTER  Y 


OPERATIONS    ON    THE    POPLITEAL    SPACE. 

LIGATURE    OF    THE    POPLITEAL    ARTERY. 


Indications. — Extremely  few, 

Fig.  265. 


III. 


Sm'Ia 


Ligature  of  the  popliteal  artery,  i,  Deep  fascia. 
2,  Internal  popliteal  nerve.  3,  Popliteal  vein.  4, 
Popliteal  artery.  5,  Outer  head  of  gastrocnemius. 
6,  Inner  head  of  gastrocnemius.  7,  Communicans 
tibialis.  8,  External  saphenous  vein.  9,  Head  of 
fibula.     (Kocher ) 


i.  Stab  or  punctured  wound. — Here 
the  surgeon  would  only 
resort  to  ligature,  (i)  if 
pressure  was  unavailing  ; 
(2)  if  the  patient  insisted 
on  running  the  risk  of 
gangrene  ;  (3)  it  would  be 
well,  if  possible,  to  get 
leave  for  immediate  ampu- 
tation if  the  vein  was 
found  injured  also.  ii.  In 
some  cases  of  ruptured 
popliteal  artery  it  will  be 
right  to  explore  and  see  if 
any  other  complication 
exists  beyond  the  rupture 
of  the  artery.*  If  there  is 
no  injury  to  the  vein, 
nerves,  or  the  joint  (a 
very  unlikely  contin  - 
gency),  the  rupture  may 
be  treated  by  double  liga- 
tures as  elsewhere.  The 
surgeon  must  afterwards 
be  prepared  to  amputate 
through  the  lower  third  of 
the  thigh  on  the  first  sign 
of  gangrene  appearing. 
The  operation  of  ligature 
of  the  popliteal  artery  is 
extremely  difficult  here, 
owing  to  the  depth  of  the 
vessel,  the  strong  fascia, 
the  amount  of  coagulated 
blood,  and  the  infiltrated, 
obscured  condition  of  the 
parts.  Primary  amputa- 
tion will,  as  a  rule,  be 
required  in  cases  of  rup- 
tured     popliteal      artery, 


*  Poland,  Guy's  Hasp.  Be^orts,  third  series,  vol.  vi.  p.  294. 


LIGATUEE  OF  THE  POPLITEAL  ARTERY.  66 1 

especially  where  skilled  assistance  and  facilities  for  antiseptic 
treatment  are  not  at  hand.  A  free  incision  will  enable  the  surgeon 
to  investigate  the  amount  of  injury,  and  at  the  same  time  will 
relieve  tension  if  an  attempt  be  made  to  save  the  limb.  This  incision 
may  form  part  of  the  amputation  (p.  633).  iii.  The  artery  has  been 
wounded  in  the  course  of  an  osteotomy  of  the  lower  end  of  the  femur. 
In  such  a  case  the  vessel  should  be  reached  by  the  incision  shown  in 
Fig.  266.  iv.  "Possibly  in  a  small  traumatic  aneurysm"  (Sir  W. 
Mac  Cormac,  Lvjature  of  Arteries,  p.  109).  If  any  surgeon  is  inclined  to 
perform  the  old  operation  for  a  ruptured  popliteal  aneurysm,  he  should 
first  consult  a  clinical  lecture  on  a  case  of  this  kind  by  Mr.  Holmes. 
The  difficulties  which  may  be  expected  are  graphically  described,  and 
the  wisdom  of  amputation  shown. 

Extent. — From  the  opening  in  the  adductor  magnus  to  the  lower 
border  of  the  popliteus. 

Guides. — Behind :  A  line  di-awn  from  just  inside  the  imier  hamstrings 
above  to  the  centre  of  the  lower  part  of  the  popliteal  space.  In  front : 
The  tendon  of  the  adductor  magnus. 

Eelations  (in  the  popliteal  space)  : 

Behind. 

Skin ;    fascia? ;    small     sciatic    nerve,    above ;   short 

saphena  vein  and  external  saphena  nerve,  below ; 

fat ;  o-lands. 
Semi-membranosus,    above  ;     gastrocnemius,    plan- 

taris,  soleus,  below. 
Internal    popliteal    nerve ;    popliteal    vein,    outside 

above,  inside    below,    exactly  over   the   artery  in 

the  centre  of  the  space. 
Branch  of  obdurator  above. 

Outside.  Inside. 

Biceps,  above  ;  gastrocnemius  Semi-membranosus,  above  ; 
and  plantaris,  below.  gastrocnemius,  below. 

Popliteal  artery. 

In  Front. 

Femur. 

Posterior  ligament. 

Popliteus. 

Collateral  Circulation, 

AiK)VE.  Below. 

Anastomotica  magna,  supe-  Inferior  articular,  and  re- 

rior  articular,  descending  ..  ,  current    from    anterior 

branch    of    external    cir-  tibial, 

cumflex. 

Operations  (Figs.  265,  266).— The  artery  may  be  tied  in  three 
places.  A.  At  the  upper  part  of  the  popliteal  space.  B.  At  the  lower 
part  of  the  popliteal  space.  C.  From  the  front,  at  the  inner  side  of  the 
limb.  For  the  sake  of  experience,  all  should  be  practised  on  the  dead 
bodv. 


662  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

A.  At  the  Upper  Part  of  the  Popliteal  Space. — The  patient 
being  rolled  two-thirds  on  to  his  face,  and  the  limb  at  first  extended, 
an  incision  three  inches  and  a  half  long  is  made,  in  the  line  of  the 
vessel,  along  the  outer  margin  of  the  semi-membranosiis,  and  then 
downwards  and  outwards  to  the  centre  of  the  space.  The  small  sciatic 
nerve,  if  seen,  should  be  drawn  to  one  side  ;  the  deep  fascia  is  then 
freelj^  opened  up,  and  the  pulsation  of  the  artery  felt  for  at  the  outer 
margin  of  the  semi-membranosus.  The  nerve  is  generalh^  seen  first, 
and  this  and  the  vein  are  to  be  drawn  to  the  outer  side  with  blunt 
hooks.  The  needle  should  be  passed  from  the  vein.  A  good  deal  of 
loose  fat  is  usually  in  close  contact  with  the  vessels,  and  is  liable  to  be 
a  source  of  trouble  wherever  the  artery  is  ligatured,  especially  in  the 
dead  subject. 

B.  At  the  Lower  Part  of  the  Popliteal  Space  (Fig.  265). — The 
limb  being  in  the  same  position,  an  incision  three  inches  and  a  half 
long  is  made,  in  the  line  of  the  artery,  from  the  centre  of  the  popliteal 
space  to  the  junction  of  the  upper  and  middle  thirds  of  the  back  of  the 
leg.  The  external  saphena  vein  and  its  nerve  being  avoided,  the  deep 
fascia  is  freely  oj^ened  and  the  limb  flexed.  The  exact  interval  bet\\'een 
the  heads  of  the  gastrocnemius  is  next  sought  for.  The  following 
structures  may  now  be  met  with  overlying  the  artery,  and  must  be 
drawn  aside — viz.,  the  plantaris,  the  sural  arteries  which  run  down  on  the 
vessel,  and  the  communicans  tibialis  nerve.  The  popliteal  vein  now  lies 
to  the  inner  side,  together  with  the  popliteal  nerve,  which  is  superficial 

to  it,  if  this  has  not  given  off 
Fig.  256.  its  branches.      These    struc- 

tures should  be  drawn  to 
either  side,  and  the  needle 
passed  as  is  convenient. 

C.  From  the  Front,  at 
the  Inner  Side  (Fig.  266). 
— This  operation  might  be 
useful  in  cases  where  haemor- 
rhage recurs  after  osteotomy 
.psss^  ^^      ^^  tlie  lower  end  of  the  femur 

"*  ^      (p.  661). 

The  following   account  is 
*,— '-      III)  /-  -i^^^a    taken    from    Sir  Wm.    Mac 

lyormac  {Jjiqahire  oj  Arteries, 

The  artery  lies  embedded  in  fat.    Above  it  are  j  jq)  :    "  Flex  the  knee  and 

some  01  the  fibres  of  the  adductor  maguus.     In        ■"-  ,  i       t     i  +1 

the  upper  angle  of  the  wound  the  sartorius  has       PJace  the  Imib    on    the    outer 

been  drawn  down.  side.    Make  an  incision  three 

inches  long  immediately  be- 
hind and  parallel  to  the  tendon  of  the  adductor  magnus  downwards 
from  the  junction  of  the  middle  and  lower  thirds  of  the  thigh.  Divide 
the  skin,  superficial  and  deep  fasciae,  avoid  the  long  saphenous  nerve, 
seek  the  tendon  of  the  adductor  magnus,  draw  it  forwards  and  the  ham- 
string tendons  backwards.  The  artery  will  then  be  found  surrounded 
by  fatty  areolar  tissue.  The  nerve  and  vein  do  not  necessarily  come 
into  view,  being  on  the  external  aspect  of  the  vessel." 


CHAPTER  VI. 
OPERATIONS   ON    THE   LEG. 

LIGATURE  or  POSTERIOR  TIBIAL  ARTERY.— LIGATURE 
OF  ANTERIOR  TIBIAL  ARTERY.— LIGATURE  OF  PERO- 
NJEAL  ARTERY.— AMPUTATION  OF  LEG.— OPERATION 
FOR  NECROSIS.— TREATMENT  OF  COMPOUND  FRAC- 
TURE.—OPERATION  FOR  SIMPLE  FRACTURE.— EXCI- 
SION   OF   VARICOSE   VEINS. 

LIGATURE     OF     THE    POSTERIOR     TIBIAL    ARTERY. 

Indications. — Very  rare.  i.  Chiefly  Wounds. — Mr.  Cripps.*  in  a  very 
valuable  ]>aper,  divides  up  the  sources  of  hsemorrhage  from  the  upper 
two-thirds  of  the  posterior  tibial  into  ( i )  haemorrhage  after  amputation  ; 
(2)  haemorrhage  from  injury  to  the  vessels  in  continuity,  (i)  Haemor- 
rhage after  Amputation. — This  is  usually  due  to  a  diseased  condition  of 
the  vessels,  and  to  the  fact  that  the  vessels  lying  between  the  bones  are 
now  especially  difhcult  to  take  up.  If  from  their  constantly  breaking 
away  it  is  found  impossible  to  deal  with  them,  the  limb  should  at  once 
be  amputated  above  the  knee.  If  the  hemorrhage  occurs  later  on,  well- 
adjusted  pressure  (p.  617)  should  be  carefully  tried,  aided  or  followed 
by  ligature  of  the  feinoral  or  by  amputation  higher  up.  (2)  Haemor- 
rhage from  Wounds  of  the  Tibials  in  Continuity. — Three  chief  causes 
may  lead  to  this  :    {a)  An  incised  wound,     (h)  A  punctured  wound. 

(c)  Wounds  other  than  punctured  or  incised.  Four  methods  of  treat- 
ment are  open  to  the  surgeon — viz.,  (ci)  Pressure  and  bandaging. 
(6)  Ligature  of  both  ends  of  the  vessel,     (e)  Ligature  of  the  femoral. 

(d)  Amputation,  (a)  Incised  Wound. — If  this  is  seen  soon  after  its 
infliction,  the  bleeding  point  should  be  sought  for  and  tied,  the  wound 
being  enlarged  if  needful.  If  sloughing  and  extravasation  of  blood 
have  taken  place,  amputation  will  probably  be  the  wiser  course,  though, 
if  the  patient  decide  to  run  the  risk,  an  attempt  may  be  made  to 
save  his  limb  by  making  free  incisions,  providing  drainage,  plugging 
the  wound  (rendered,  as  far  as  may  be.  aseptic  with  irrigation  and  iodo- 
formj  with  aseptic  gauze,  bandaging  evenly  and  firmly,  and  tying  the 
femoral  in  Hunter's  canal,  {li)  Fundured  M'ound. — If  this  is  deep,  and 
the  vessel  injured  uncertain,  the  question  of  treatment  is  a  very  serious 

*  St.  Barthol.  Hosp.  RepoHs,  vol.,  xi.  p.  94  ;  Diet,  of  Surg.,  vol.  ii.  p.  626. 


664 


OPERATIONS  ON  THE  LOWER  EXTREMITY. 


one.*     Mr.  Cripps  shows  that,  in  the  raajorit}^  of  instances,  pressure 
deserves  a  fair  and  thorough  trial.     If  it  is   iTseless,  or  prejudicial  to 


Anterior  tibial  recurrent 


Posterioi  tibial 


Fig.  267. 
Diagram  of  the  colla- 
teral branches  aud  arte- 
rial commuuications  iu 
the  leg  and  at  the  ankle. 
(Mac  Cormac.j 


Internal  malleolar 

Internal  calcancan  

Posterior  internal  malleolar 

Internal  plantar 

External  plantar  • 

Scaphoid  bone 


Popliteal. 


Anterior  tibial. 
Posterior  tibial  recurrent. 


Superior  fibular. 


Anterior  peronceal. 
Posterior  peroniral. 

Communicating. 

External  malleolar. 

Astragalus. 

External  calcancan  branch. 


Calcaneum. 


other  treatment,  either  the  femoral  must  be  tied  or  the  wound  enlarged 
to  secure  the  wounded  vessel.     Between  these  operations  the  features  of 

*  AVhere  the  wound  has  passed  obliquely,  Dupuytren's  words  should  be  remembered. 
They  refer  to  hcemorrhage  from  the  calf  caused  by  a  pistol-bullet.  "  Should  a  ligature 
be  placed  on  the  ends  of  the  divided  vessel  ?  But  what  were  those  vessels  ?  Was  it 
the  anterior  or  posterior  tibial,  or  the  peronosal  or  the  popliteal  ?  "Was  it  several  of 
them  at  the  same  time  ?     Should  they  be  attacked  before  or  behind  ?  " 


LIGATURE  OF  THE  POSTERIOR  TIBIAL  ARTERY.  665 

the  particular  case  must  decide.  If  pressure  is  made  use  of,  it  should  be 
applied  methodically  and  with  intelligent  purpose  (p.  617),  and  so  that 
it  needs  no  alteration  or  i-epetition.  (c)  Wounds  other  than  Punctured 
or  Incised. — viz..  Injury  to  the  Vessel  from  Fracture  or  Gunshot  Wound. — 
In  many  cases  conditions  will  be  present  which  will  call  for  amputation 
— viz.,  the  severity  of  the  crush ;  the  extent  of  the  comminution ;  injur}^ 
to  the  nerves  or  to  both  arteries,  as  evidenced  by  the  condition  of  the 
foot ;  and  the  age  or  the  health  of  the  patient.  In  most  of  these  cases, 
as  an  attempt  to  find  the  vessel  involves  great  difficulty  and  danger,  and 
the  probabilities  of  success  diminish  as  the  interval  between  the  inflic- 
tion and  treatment  of  the  injury  increases,  ligature  of  the  femoral  would 
be  less  hazardous  than  any  interference  with  the  wound.  But  amputa- 
tion will  frequently  be  needed.  The  above  remarks  apply  to  compound 
fractures  ;  an  instance  of  successful  ligature  of  a  lacerated  femoi-al  co- 
existing with  a  simple  fracture  of  the  leg  is  given  at  p.  613.  ii.  Small 
traumatic  aneurysms,  iii.  The  posterior  tibial  ma}'  be  tied  low  down, 
together  with  the  dorsalis  pedis,  for  certain  wounds  of  the  sole  or  for 
some  vascular  growths  of  the  foot. 

Line  a^d  Guide. — A  line  drawn  from  a  point  at  the  lower  part  of  the 
centre  of  the  popliteal  space*  to  one  midway  between  the  tendo-Achillis 
and  the  internal  malleohxs. 

Relations. — These  differ  according  as  the  vessel  is  tied — (A)  in 
the  middle  of  the  leg,  (B)  in  the  lower  third  of  the  leg,  (C)  at  the  inner 
ankle. 

A.  Relations  in  the  Middle  of  the  Leg  : 

Superficial. 
Skin ;  fasciae ;  branches  of  saphense  veins  and  nerves. 
Gastrocnemius  ;  soleus  ;  plantaris. 
-    Special  fascia  ;  transverse  branches  of  venee  comites ; 
tendinous  origin — arch — 'of  soleus  (above). 
Outside.  Inside. 

Vena  comes.  Vena  comes. 

Posterior  tibial  nerve  Posterior  tibial  nerve 

which   has  crossed  Posterior  tibial.  (above), 

above      from      the 
inner  side. 

Beneath. 
Flexor  longus  digitorum. 
Tibialis  posticus. 

B.  lielations  in  Lower  Third  of  Leg  : 

Superficial. 
Skin  ;  fascia3 ;  superficial  veins  and  nerves. 

Outside.  Inside. 

Vena  comes.  Vena  comes. 

Posterior  tibial  nerve.  Posterior  tibial. 

Tendo-Achillis. 

Beneath. 
Flexor  longus  digitorum. 
Tibia. 


*  This  point,  representing  the  lower  border  of  the  popliteus,  would  be  about  two 
inches  and  a  half  below  the  knee-joint. 


666  OPERATIOXS  OX  THE  LOWER  EXTRE3IITY. 

0.  Belations  at  Inner  AnMe  : 

Superficial. 

Skin  ;  fasciae  ;  branches  of  internal  saphena  vein 

and  nerve. 
Internal  annular  ligament. 


Outside, 

Vena  comes. 

Flexor  longus  pollicis. 

Posterior  tibial  nerve. 


Posterior  tibial. 

Beneath. 
Internal  lateral  ligament. 


Inside. 

Vena  comes. 
Flexor  longus  digi- 

torum ;      tibialis 

posticus. 


Fig.  268. 


Ligature  of  the  xjosterior  tibial  artery.     (Heath.) 

A,  Incision  for  ligature  of  the  artery  in  the  leg. 

B,  Incision  for  ligature  of  the  artery  at  the  inner  ankle. 

I,  Gastrocnemius.     2,  Flexor  longus  digitorum.     3,  Soleus.    4,  Tibialis  posticus. 
5,  Posterior  tibial  artery.     7,  Posterior  tibial  nerve.     9,  Tendo-Achillis. 


LIGATURE  OF  THE  POSTERIOR  TIBIAL  ARTERY. 


667 


Operation  in  Middle  of  Leg  (Figs.  268  and  269). 

The  parts  having  been  cleansed,  the  knee  flexed,  and  the  limb  sup- 
ported on  its  outer  side,  the  surgeon,  standing  or  sitting  on  the  inner 
side,  makes  an  incision  three  and  a  half  inches  long,  parallel  with  the 
centre  of  the  inner  border  of  the  tibia,  and  half  or  three-quarters  of  an 
inch  behind  it  according  to  the  size  of  the  limb.  This  incision  divides 
skin  and  fasciae.  If  the  internal  saphenous  vein  is  met  with,  it  must 
be  drawn  aside  with  a  strabismu^^-hook  ;  any  of  its  branches  may  be 
divided  between  two  ligatures.  The  deep  fascia  is  then  freely  slit  up, 
and  the  inner  edge  of  the  gastrocnemius  defined  and  drawn  backwards. 
This  will  expose  the  soleus,  the  tibial  attachment  of  which  is  to  be  cut 
through,  anj^  sural  artery  being  at  once  secured.  The  incision  through 
the  soleus  (Fig.  269)  should  be  three  inches  long  and  quite  half  an  inch 
from  the  tibia;  as  the  fibres  are  divided,  the  central  membranous  tendon 
will  come  into  view,  and  must  not  be  confused  with  the  special  deep 
fascia  or  intermuscular  septum  over  the  deep  flexors.     Usually,  before 

Fig.  260. 


Ligature  of  the  posterior  tibial  at  the  middle  of  the  calf.  The  iuner  head  of 
the  gastrocnemius  is  drawn  backwards  by  retractors.  The  left  index  raises 
the  anterior  lip  of  the  wound  while  the  soleus  is  divided  peri^endicularly  to 
its  surface.     (Farabeuf.) 

this  comes  into  view,  some  additional  fibres  have  to  be  divided.  When 
this  is  done,  the  above  special  fascia  must  be  identified,  stretching 
between  the  bones.  The  wound  must  be  carefully  dried,  well  opened 
out  with  retractors,  and  exposed  with  a  good  light  at  this  stage.  The 
deep  fascia  being  opened  carefully,  the  nerve  usiially  comes  into  view 
first,  the  artery  lying  a  little  deeper  and  more  external.  The  venae 
comites  should  be  sepai*ated  as  far  as  possible,  but  rather  than  puncture 
them  and  cause  hsemorrhage  at  this  stage,  or  waste  time,  the  surgeon 
should  tie  them  in.  The  needle  should  be  passed  from  the  nerve.  To 
facilitate  this,  the  knee  should  be  well  flexed,  and  the  foot  also  flexed 
downwards  so  as  to  relax  the  muscles  thoroughly.  The  ligature  will 
lie  below  the  peronaeal  artery. 

Operation  in  Lower  Third  of   Leg. — The  limb   and  the 

operator  being  in  the  same  position  as  before,  an  incision  two  and 
a  half  inches  long  is  made  through  skin  and  fascite,  parallel  with  the 
inner  border  of  the  tibia,  and  midway  between  it  and  the  tendo- 
Achillis  ;  after  the  deep  fascia  has  been  opened,  another  layer,  tying 
down  the  deep  flexor  tendons,  will  require  division.     The  artery  here 


668  OPERATIOXS  ON  THE  LOWER  EXTREMITY. 

lies  between  the  flexor  longus  digitorum  and  pollicis,  siirrounded  by 
vena3  comites.  The  needle  should  be  passed  from  the  nerve,  which  lies 
to  the  outer  side.  If  the  incision  is  made  too  high,  some  of  the  lowest 
fibres  of  the  soleus  will  require  detaching  from  the  tibia ;  if  too  low, 
the  internal  annular  ligament  would  be  opened.  The  sheaths  of  the 
flexors  (their  sj^novial  investment  commences  about  an  inch  and  a  half 
above  the  internal  malleolus)  should  not  be  interfered  with. 

Operations  at  the  Inner  Ankle  (Fig.  268). — The  limb  and  operator 
being  placed  as  before,  a  curved  incision,  two  inches  long,  is  made, 
three-quarters  of  an  inch  behind  the  internal  malleolus.  Skin  and 
fasciae  being  divided,  any  branches  of  the  internal  saphena  vein  tied, 
the  internal  annular  ligament  is  divided,  and  the  artery  found  closety 
surrounded  by  its  veins.  The  nerve  lies  externally,  and  the  needle 
should  be  passed  from  it.  The  arter}^  is  so  superficial  here  that  the 
veins  can  be  easil}-  separated.  The  nerve  has  occasionally  bifurcated 
higher  up. 


LIGATURE    OF    THE    ANTERIOR    TIBIAL. 

Indications. — These  are  very  few.  and  resemble  so  closely  those 
already  given  for  the  posterior  tibial — viz.,  wounds  and  traumatic 
aneurysm — that  there  is  no  need  to  go  into  them  again  here. 

In  the  course  of  1887,  I  ^^^d  occasion  to  tie  the  anterior  tibial  in  its 
lower  third  for  profuse  haemorrhage  from  a  compound  fracture,  not 
arrested  by  pressure. 

There  was  a  compouud  comminuted  fracture  of  the  right  leg,  in  the  lower  third,  from 
a  fall  of  4  cwt.  upon  the  limb.  The  upper  end  of  the  artery  was  found  with  some 
difficulty,  owing  to  the  pulped-up  condition  of  the  soft  parts.  Having  failed  to  find 
the  lo-arer  end,  I  was  about  to  expose  the  dorsalis  pedis,  and,  trusting  to  antiseptic 
precautions,  trace  this  up  to  the  anterior  tibial,  when,  an  urgent  strangulated  hernia 
being  admitted,  I  plugged  the  wound,  all  the  undermined  parts  being  previously  laid 
freely  open.  No  recurrence  of  bleeding  took  place,  and  the  man  (aged  44)  made  an 
excellent  recovery,  aided  by  his  temperate  life  and  patient  ways,  the  freedom  with 
which  the  wound  was  laid  open  (this  preventing  all  retention  of  discharges),  the  use 
of  dry  gauze  dressings  only  changed  at  rare  intervals,  and,  not  least,  the  fact  that 
iodoform  was  thoroughly  dusted  in. 

Dr.  Shepherd,  of  Montreal  (Ann.  of  Surg.,  No.  i,  p.  7),  gives  another, 
but  more  difficult,  case  in  which  the  compound  fracture  was  about  the 
junction  of  the  middle  with  the  upper  third  of  the  leg. 

The  bleeding  was  first  arrested  by  pressure.  On  the  fourth  day  a  traumatic  aneurysm 
appeared.  The  artery  was  exposed  with  difficulty,*  and  found  partly  divided ;  two 
ligatures  were  applied,  and  the  patient  made  a  good  recovery. 

Dr.  Shepherd  points  out  that,  the  injury  to  the  vessel  being  just  in  front  of  the 
place  where  it  pierces  the  interosseous  membrane,  if  the  artery  had  been  completely 
torn  through  it  would  have  retracted  through  the  opening,  and  ligature  would  have 
been  impossible.  Mr.  F.  Page  {Lancet,  1887,  vol.  i.  p.  522)  gives  a  case  of  traumatic 
aneurj^sm  of  ten  weeks'  duration,  after  a  stab,  at  the  junction  of  the  middle  and  lower 
thirds  of  the  leg.  The  swelling  had  been  poulticed  and  opened,  with  the  result  of 
haemorrhage.  Mr.  Page,  on  clearing  out  the  clots  and  opening  up  the  swelling,  was 
unable  to  find  the  anterior  tibial  artery.  Hsemorrhage  recurring,  the  leg  was 
amputated.     The  patient  recovered. 


LIGATURE  OF  THE  ANTERIOR  TIBIAL. 


669 


Line  and  Guide. — From  a  point  midway  between  the  head  of  the 
fibula  and  the  outer  tuberosity  of  the  tibia  to  the  centre  of  the  front  of 
the  ankle-joint.     The  outer  edge  of  the  tibialis  anticus. 

Kelations  : 

Superficial, 

Skin ;    fasciae :     cutaneous    branches    of    saphenous 
veins  and  nerves,  and  (below)  musculo-cutaneous 
nerve. 
Tibialis    anticus    and    extensor    longus     digitorum 

(above),  overlapping. 
Tibialis  anticus  and  extensor  longus  pollicis  (below), 
overlapping. 

Outside.  Anterior  tibial  artery. 

Extensor  longus  digitorum  (above). 
Extensor  longus  pollicis  (below). 
Anterior  tibial  nerve. 
Vein. 

Beneath. 
Interosseous  membrane. 

Operation  at  the  Junction  of  the  Upper  and  Middle  Thirds  of 
Leg  (Figs.  27c,  271). — The  knee  being  flexed  and  the  limb  supported 
upon  its  inner  side,  the  surgeon  having  defined,  if  possible,  the  outer 
edge  of  the  tibialis  anticus,*  sits  or  stands  on  the  outer  side  of  the 
patient,  and  makes  an  incision  about  four  inches  long  in  the  line  of  the 
artery,  beginning  '^ — "  ^        •     ^  --   i    1        .■>     •>      t    f  .-,      .■-,  ■        rr,,  . 


Inside. 
Tibialis  anticus. 
Vein. 


about  two  inches  below  the  head  of  the  tibia.     This 


Fig.  270. 


Ligature  of  the  anterior  tibial  artery  at  the  junction  of  the  middle 
and  upper  thirds;  division  of  the  deep  fascia  on  a  director  (p.  671). 
(Farabeuf.) 

incision  should  lie  (if  the  edge  of  the  muscle  has  not  been  marked  out) 
three-quarters  to  one  inch — according  to  the  size  of  the  leg — from  the 
crest  of  the  tibia,  and  should  expose  the  deep  fascia  carefully,  so  that  the 
white  line  which  marks  the  desired  intermuscular  septum  ma}^  be 
looked  for.  This  line  is  often  whitish-yellow,  and  varies  much  in  dis- 
tinctness.   If  there  is  any  difficulty  in  finding  it,  any  bleeding  points  must 


The  patient  may  put  this  into  action  just  before  the  ansesthetic  is  taken. 


670 


OPER-\TIOXS  OX  THE  LOAVEE   EXTPuEMlTY, 


be  secui'ed.  and  the  deep  fascia  slit  up  over  the  line  of  the  arteiy,  and 
the  finger-tip  inserted  to  feel  for  the  sidcus  between  the  muscles.     A 


Fie.  271. 


Ligature  of  the  anterior  tibial  artery.     (Heath. 
A  and  B.  Incisions  for  ligature  of  the  anterior  tibial  artery. 
C,  Incisions  for  ligature  of  the  dorsaUs  pedis  artery. 
I.  Extensor  longus  digitorum.     2.  Anterior  tibial  vessels  and  nerve.     3,  Ertensor 

proprius  hallucis.     4.  Tibial  anticus.     5,  Peroneus  tertins.     6,  Anterior  tibial 

nerve.    7,  Dorsalis  pedis  arterj-. 

third  aid  is  almost  constant,  and  that  is  a  small  muscular  artery*  which 
comes  up  between  the  tibialis  and  the  extensor  longus  digitorum.     The 

*  This  is  pointed  out  by  Mr.  C.  Heath  QOj>er.  Surff..  p.  47).     I  have  found  the  same 
ihing  most  helpful  in  the  ligature  of  the  ulnar  in  the  middle  third. 


LIGATUEE  OF  THE  PEEOX.EAL  ARTERY.  67 1 

sulcus  being  found  between  the  muscles  (without  tearing  them),  they 
are  separated  with  the  handle  of  a  scalpel  or  a  steel  director,  and 
retractors  inserted,  the  outer  one  being  hooked  over  the  fibula.  If  the 
limb  is  a  very  muscular  one,  the  deep  fascia  should  be  nicked  trans- 
versely at  the  upper  and  lower  extremities  of  the  wound,  and  the  parts 
more  relaxed  by  bending  the  knee  more  and  pressing  the  foot  upwards. 
The  finger  now  directed  towards  the  interosseous  space  feels  for  the 
artery  deep  down  in  the  bottom  of  the  wound.  The  nerve  should  be 
di*awn  to  the  outer  side.  If  much  trouble  is  met  ^\'ith  in  separating  the 
venjB  comites.  they  may  be  included. 

In  a  case  which  still  presents  diliiculties  the  following  dii-ections  of 
M.  Farabeuf  may  be  iiseful  (Man.  Oper.,  p.  89):  The  two  lips  of  the 
wound  having  been  separated,  the  deep  fascia  is  opened  close  to  the 
inner  lip  and  the  grooved  director  introduced  *  beneath  it.  and  pushed 
across  gently  i^aitil  its  tip  is  arrested  by  the  firsr  intermuscular  interval 
and  septum,  that  between  the  tibialis  anticus  and  the  extensor  digi- 
torum.  If  the  operator  pushes  it  too  far  it  ^ill  be  arrested  by  the 
better  marked  septum  between  the  peroneei  and  extensors.  In  ciitting 
upon  it  the  operator  will  have  crossed  the  desired  interval. 

Drainage  having  been  provided,  and  all  ha?morrhage  stopped,  the 
■oound  is  lightly  dusted  with  iodoform,  the  muscles  united  with  one 
or  two  chromic-gut  sutures,  and  the  wound  closed,  the  limb  being  kept 
raised  and  flexed. 

Operation  at  the  Junction  of  the  Lower  and  Middle  Third  of  Leg 
(Fig.  271.  b). — An  incision  about  two  inches  and  a  half  long  is  made  in 
the  line  of  the  artery ;  in  the  upper  part,  this  incision  will  be  about  one 
inch  from  the  ti1;>ia.  The  white  line  and  the  interval  between  the 
tibialis  anticus  and  the  extensor  proprius  pollicis  are  both  looked  and 
felt  for.  The  deep  fascia  being  divided  and  the  muscles  relaxed  and 
retracted,  the  artery  is  found  surrottnded  by  its  venos  comites.  The 
needle  must  be  passed  from  without  inwards. 


LIGATUEE    OF    THE     PERON-51AL    ARTERY. 

Indications. — As  these  are  extremely  few,  and  as  in  the  case  of  a 
wound  of  the  vessel  (which  is  very  rarely  met  with)  the  best  course 
would  be  to  enlarge  the  wound,  any  formal  operation  for  its  ligature 
need  only  be  very  briefly  described. 

Eelations. — The  peromeal  artery  comes  ofl'  from  the  posterior  tibial 
about  one  inch  below  the  popliteus,  descends  at  first  parallel  with  this 
arteiy  but  separated  from  it  by  the  posterior  tibial  nerve  ;  it  then  passes 
outwards  towards  the  fibula,  and  runs  down  between  this  bone  and  the 
flexor  long-US  hallucis.  In  the  upper  part  of  its  course  it  lies  upon  the 
tibialis  posticus,  and  is  covered  by  the  soleus. 

Operation. — To  tie  the  artery  when  no  wound  is  present  to  guide  the 
surgeon,  an  incision  thi'ee  inches  long  should  be  made  along  the 
posterior  border  of  the  fibula,  with  its  centre  at  the  junction  of  the 
upper  and  middle  thirds  of  the  leg.     The  gastrocnemius  being  drawn 

*  Though  in  Fig.  270  M.  Farabeuf  figures  the  director  introduced  from  without,  he 
directs  that  it  be  passed  as  described  above,  and  figures  it  so  in  another  illustration. 


672 


OPERATIONS  OX  THE  LOWER  EXTREMITY. 


aside,  and  the  soleus  separated  from  its  attachment  to  the  fibula,  the 
special  deep  fascia  is  slit  up.  and  the  artery  sought  for  close  to  the  fibula. 


AMPUTATION    OF    THE    LEG. 

DiflFerent  Methods.— (Figs.  272-278). 

I.  Lateral   Flaps   (Figs.   272-275).     2.  Teale's  Rectangular  Flaps 
(Figs.    276-278).      3.  Antero-posterior    Flaps    of   Skin.      4.  Antero- 


FiG.  273. 


Fig.  272. 


Amputation  of  the  leg  by  lateral  flaps. 
(Farabeuf.) 


Amputation  of  the  leg  by- 
lateral  flaps.  The  muscles  are 
being  severed  with  circular 
sweeps  of  the  knife. 


posterior  Flaps,  Anterior  of  Skin,  Posterior  by  Transfixion  of 
Muscle.      5.  Circular. 

I  shall  only  describe  the  first  two.  as  the}'  Avill  be  found  adapted  to  all 
emergencies,  and  to  be  devoid  of  the  disadvantages  of  the  others. 

I .  Lateral  Skin  Flaps,  with  Circular  Division  of  the  Muscles,  &c. 
— This  is,  I  believe;  a  method  not  well  known  be^'ond  Guy's  and  those 
who  have  been  taught  there.  It  will  not  only  be  found  most  convenient 
at  the  time,  but  it  also  gives  very  satisfactor}'  results  afterwards.  The 
blood-supply  is  well  and  equally  distributed  to  the  lateral  flaps,  one  can 
be  conveniently  cut  longer  than  the  other,  and  they  are  more  easily 


AMPUTATIOX  OF  THE  LEG. 


^71 


shaped  and  dissected  up  than  antero-posterior  skin-flaps,  while  no  mass 
of  muscle  is  left  to  drag  away  from  and  expose  the  bones,  as  in  the 
antero-posterior  flaps,  with  the  anterior  of  skin  and  the  posterior  by 
transfixion. 

Operation  (Figs.  272-275). — The  femoral  artery  having  been  com- 
manded, the  leg  brought  over  the  table,  and  the  damaged  or  diseased 
parts  bandaged  in  carbolised  lint — so  as  to  give  the  assistant  a  firm  hold 
and  also  to  prevent  his  soiling  the  flaps  later  on — the  opposite  ankle  is 
tied  to  the  table.  The  surgeon,  standing  to  the  right  of  the  limb,  places 
his  left  index  on  the  crest  about  an  inch  below  the  tubercle,  and  his 
thumb  at  a  corresponding  point  behind  in  the  centre  of  the  limb. 
Looking  over  he  inserts  his  knife  close  to  the  thumb,  and  cuts  on  the 
side  of  the  limb  farthest  from  him  a  lateral  flap  broadly  oval  in  shape 
and  three  inches  long,  ending  at  the  index  finger,  from  which  point, 
without  removing  the  knife,  a  similar  flap  is  marked  out  ending  on  the 
back  where  the  first  began.     Flaps  of  skin  and  fascia  are  now  dissected 


Fig.  275. 


Amputation  of  the  legat  the  seat  of  election^ 
by  lateral  flaps,  a  good  stump  resulting 
(Farabeuf.) 


Amputation  of  the  leg  by  lateral 
flaps,  at  the  seat  of  election.  The 
posterior  muscles,  cut  too  high, 
have  retracted  greatly,  and  an  ugly 
conical  stump  is  the  result.  (Fara- 
beuf.) 


up.  and  the  muscles  all  cut  through  with  a  circular  sweep  of  the  knife 
at  the  intended  point  of  bone-section,  this  sweep  being  repeated  two  or 
three  times  till  the  soft  parts  are,  all.  cleanly  severed.  The  posterior 
muscles  should  be  cut  a  little  longer  than  those  in  front,  owing  to  their 
greater  retraction  (Figs.  274.  275).  The  interosseous  membrane  is  next 
divided,  so  that  it  shall  not  be  frayed  by  the  saw,  and  w4th  one  final, 
firmly  drawn,  circular  sweep  the  periosteum  is  grooved  for  the  saw.* 
This  is  then  applied  with  the  following  precautions.  The  position  of 
the  fibula  behind  the  tibia  and  its  much  smaller  size  must  be  remem- 
bered, lest  it  be  splintered.  This  may  be  avoided  by  rolling  the  leg 
well  over  on  to  the  inner  side,  and  placing  the  saw  well  down  on  the 
outer  side  so  as  to  start  the  section  of  the  bones  simultaneously,  and 
thus  ensure  complete  division  of  the  fibula  before  the  tibia.  This 
object  may  also  be  effected,  if  the  leg  is  held  in  the  ordinary  position, 
by  applying  the  saw  to  the  tibia,  and  remembering,  when  this  bone 
has  been  sawn  half-through,  to  depress  tHe  handle,  and  thus  complete 

*  Xowadays,  with  antiseptic  precautions,  the  old  need  of  periosteal  flaps — viz..  to 
keep  pus,  kc.  out  of  the  cliploe  and  medullary  canal — is  no  longer  present.  Further- 
more, these  flaps  are  very  difficult  to  raise,  unless  inflamed,  especially  in  the  thin 
periosteum  of  adults. 

VOL.  II.  43 


6/4 


OPERATIONS  OX  THE   LOWER  EXTREMITY. 


the  section  of  the  bones  simultaneously.  In  either  case  the  saw  should 
be  used  lightly  and  quickly,  with  the  whole  length  of  the  blade,  and 
without  jamming.     As  the  sharp  projecting  angle  of  the  crest  tends  to 


Fig.  276- 


come  through  the  anterior  angle  of  the  flaps,  this  may  be   sawn  off 
obliquely  after  the  bones  are  sawn. 

Teale's  Amputation  by  Rectangular  Flaps  (Figs.  276-278). — This 
method  is  rarely  employed.  In  hospital  practice,  where  amputation  of 
the  leg  is  usually  called  for,  amputation  at  "  the  seat  of  election,"  so 
that  the  patient  can  bear  his  weight  on  parts  used  to  pressure,  is 
always  preferable,  and  lateral  flaps  give  here  the  best  results,  at  the 
least  expense  of  tissue,  and  in  the  shortest  time.  In  the  better  ranks 
of  life,  where  the  patient  can  afford  and  use  comfortably  a  well-moulded 
leather  socket,*  a  longer  stump  may  be  made,  as  the  pressure  will  now 
not  be  taken  on  the  face  of  the  stump,  but  distributed  over  the  socket. 

Fig.  277. 


Advantaries. —  i.  The  covering  for  the  bones  is  am yjle,  and  the  flaps 
come  together  without  tension. f     2.  The  way  in  which  the  flaps  are 

*  Hospital  patients  occasionally  ask  for  and  get  together  the  money,  on  the  first 
occasion,  for  one  of  these  expensive  legs.  The  well-moulded  socket  on  which  the 
bearing  of  the  weight  comfortably  depends  is  quite  unfitted  for  the  hard  wear  and 
tear,  perspirations,  &c.,  to  which  it  will  be  submitted. 

f  Save  when  infiltrated,  the  difficulty  of  getting  the  anterior  flap  into  position  is 
then  often  considerable. 


AMPUTATION  OF  THE  LEG. 


675 


united  favours  drainage  during  healing,  and  provides  a  scar  well  out  of 
the  way  of  pressure.     3.  The  stump  bears  pressure  well. 

Disadvantages. — I.  It  is  an  expensive  method,  involving  a  high 
section  of  the  bones.  2.  The  long  anterior  flap  ma^^  slough.  3.  If 
performed  with  the  accuracy  of  its  introducer,  it  involves  more  time 
than  that  by  lateral  flaps  (vide  supra),  and  is,  thus,  not  suited  to  cases 
of  shock. 

Operation. — The  preparatorj"  steps,  and  the  position  of  the  operator 
and  patient,  are  as  at  p.  6y;^.  The  surgeon  ha\ang  measured  the 
circumference  of  the  limb  at  the  spot  where  he  intends  to  saw  the 
bones,  and  placing  here  his  left  index  and  thumb  on  the  tibia  and 
fibula,  traces  out  a  long  rectangular,  anterior  flap  which  is  to  be,  both 
in  its  length  and  breadth,  equal  to  half  the  above  circumference.*  In 
tracing  this  flap  the   incision  starts  from  the  index  finger,  runs  down 


Fig.  278. 


Teale. 

along  the  bone  farthest  from  the  surgeon  for  four  inches  and  a  half  (if 
the  circumference  at  the  site  of  bone-section  is  nine  inches),  then 
crosses  the  limb,  cutting  all  the  structui*es  down  to  the  bones — this  end 
of  the  flap  being  also  four  inches  and  a  half  wide — and  then  travels  up 
along  the  opposite  bone  to  the  surgeon's  thumb.  The  anterior  flap  is 
then  dissected  up  partly  with  the  knife — e.;/..  on  the  inner  side,  where 
the  scant)-  coverings  must  be  raised  as  thick  as  possible  and  without 
scoring,  partly  with  the  knife  and  partly  with  the  finger  on  the  outer 
aspect,  Avhere  the  extensors,  anterior  tibial  vessels,  and  nerves  must  be 
stripped  up,  uninjured,  from  the  interosseous  membrane  (Fig.  277).  The 
posterior  flap,  which  has  been  previously  marked  out  fullv  one-third  in 
length  of  the  anterior,  is  now  made  by  the  surgeon  looking  over  the 
limb  and  passing  his  knife  beneath  it,  and  cutting  ever3-thing  down  to 
the  bones.  It  is  next  raised  as  high  as  the  point  where  the  bones  are 
to  be  sawn.  The  interosseous  membrane  and  the  bones  are  then 
attended  to  with  the  precautions  given  at  p.  673. 


*  lu  the  lower  third,  where  the  leg  tapers  quickly,  care  must  be  taken  to  keep  this 
flap  of  the  same  width  below  as  it  is  above. 


^je  OPEEATIOXS  OX  THE  LOAVEE  EXTREMITY. 

The  vessels  being  secured  and  drainage  provided,  the  anterior  flap  is 
folded  over  the  bones  (care  being  taken  not  to  double  it  too  sharply),  its 
cut  end  stitched  to  the  cut  end  of  the  posterior  flap,  and  the  portion 
folded  below  the  bones  stitched  to  that  folded  above  them  (Fig.  278). 


SEQUESTROTOMY. 

As  the  removal  of  necrosed  bone  is  most  frequently  required  in  the 
leg,  the  above  operation  will  be  described  here. 

Indications. — The  question  will  often  arise  as  to  whether  the  case  is 
ripe  for  operation.  The  chief  points  bearing  upon  this  and  the  loose- 
ness of  the  sequestrum,  are — (i)  The  time  that  has  elapsed  since  the 
beginning  of  the  illness  ;  thus,  two  to  three  months  will  probably  be 
required  in  the  case  of  the  tibia,  but  more  likeh"  six  in  that  of  the 
femur;  (2)  the  age  and  general  health*  of  the  patient.  The  younger 
the  patient,  and  the  more  vigorous  his  vitality,  the  more  rapidly  will 
the  sequestrum  become  detached;  (3)  the  size  of  the  sequestrum.  The 
larger  and  more  tubular  the  sequestrum,  the  slower  will  be  the  process ; 
(4)  the  feel  of  the  sequestrum.  When  steel  probes  announce  this  to  be 
drj^  hard,  and  ringing,  exploration  is  justified,  especially  if  the  seques- 
trum can  be  felt  to  be  loose  or  depressed  by  the  probe;  (5)  the  size  and 
amount  of  the  new  shell  of  bone.  The  more  distinct  tliis  is,  the  more 
probable  is  it  that  the  process  of  separation  is  complete. 

Operation.! — This  should  be  always  conducted  with  strict  antiseptic 
precaution  throughout,  for  these  reasons — (a)  to  prevent  any  risk  of 
setting  up  septic  osteo-myelitis  ;  (/>)  to  diminish  the  amount  of  sup- 
puration, and  so  the  risk  of  necrosis  after  the  interference  with  the 
periosteum  which  is  entailed  by  the  operation. 

The  limb,  ha\ang  been  rendered  evascular  by  vertical  elevation  while 
the  patient  is  taking  the  anaesthetic,  and  the  application  of  Esmarch's 
bandages,  is  firmly  supported  on  sand  bags,  steel  probes  are  placed  im 
the  cloacae  which  mark  the  limit  of  the  disease,  and  with  a  strong- 
backed  scalpel  the  surgeon  makes  an  incision  between  them  on  the 
inner  surface  of  the  tibia  down  to  the  bone.  If  only  one  sinus  is 
present,  this  will  probably  be  taken  as  the  centre  of  the  incision.  This- 
incision  should  be  made  to  surround  the  sinus  or  sinuses  so  that  the 
edges  of  these  are  removed.  The  soft  parts  being  reflected,  with  every 
care  of  the  periosteum,  partly  with  the  finger,  partly  with  a  blunt  dis- 
sector, the  new  sheath  of  bone,  spongy  and  vascular,  is  thoroughly 
exposed.  This  is  then  cut  into  and  sufficientlj'  removed  with  a  chisel 
and  mallet,  to  expose  its  cavity  completely  from  end  to  end.^  The 
sequestrum  is  now  removed  with  sequestrum-forceps,  or  prised  out  with 

*  Freedom  from  syphilis  and  phthisis  will  be  noted. 

t  It  is  supposed  here  that  the  sequestrum  is  one  of  considerable  size. 

X  Mr.  Howse  (^Brit.  Med.  Jonrn.,  1874,  vol.  i.  p.  475)  lays  great  stress  on  the  need  of 
this.  The  new  bone  should  be  removed  as  far  as  the  probe  can  be  passed  upwards  or 
downwards  inside  it,  so  as  to  make  the  whole  easily  granulate  up  from  the  bottom. 
Otherwise,  the  part  that  is  not  laid  open  will  very  likely  persist  with  a  sinus.  Further- 
more, laying  the  whole  cavity  open  not  only  ensures  its  granulating  up  from  the 
bottom,  but  also  allows  of  the  removal  of  all  ill-formed  granulation  material. 


SEQUESTROTOMY. 


677 


an  elevator.  If  too  large,  it  must  be  divided  with  cutting-forceps.  The 
bed  of  ill-formed  granulation-tissue  in  which  the  sequestrum  lay  is  then 
carefully  examined  for  any  small  bit  which  may  be  concealed,  and  this 
tissue,  together  with  that  lining  the  sinuses,  is  all  scraped  away  with  a 
sharp  spoon,  and  the  cavity  left  thoroughly  cleansed  by  free  swabbing 
with  hot  carbolic  solution  (i  in  30).  When  the  surgeon  is  satisfied  that 
all  the  mischief  has  been  removed,  he  plugs  the  resulting  cavity  care- 
fully with  gauze  wrung  out  of  carbolic  lotion  (i  in  20),  dusted  with 
iodoform,  bandages  these  dressings  firmlj^  on  while  the  limb  is  elevated, 
and  not  till  then  removes  the  Esmarch's  bandage.     If  the  bandasfe  is 


Fig.  279. 


Flap  method  of  sequestrotomy. 

removed  before  the  dressings  are  applied,  such  free  venous  oozing  takes 
place  that  the  plugs  are  at  once  loosened  and  rendered  inefficient,  and 
the  wound  has  to  be  redressed  shoi-tly.  The  limb  is  kept  raised  on  a 
back  splint  and  an  injection  of  morphia  given,  if  needed. 

In  order  to  curtail  the  period  of  after-treatment,  which  is  extremely 
l)rolonged  and  tedious  o\\ing  to  the  slowness  with  which  healing  takes 
place  in  the  large  cavity  left,  an  attempt  may  be  made  in  some  cases  to 
raise  a  flap  which  includes  the  anterior  portion  of  the  involucrum,  as 
shown  in  Fio-.  279.  The  flap  h  a  cd  is  first  marked  out  by  skin  incisions 
passing  down  to  the  bone,  and  the  latter  then  divided  along  the  lines  of 


6/8  OPERATIONS  ON  THE  LOWER  EXTREMITY. 

incision  with  a  sharp  chisel  or  osteotome.  This  having  been  done,  the  flap 
is  prised  np  sufficiently  to  expose  the  cavity  in  which  the  sequestrum 
lies,  and  the  latter  then  removed.  All  the  granulation  tissue  lining 
the  cavit}^  and  the  sinuses  is  now  thoroughly  removed  with  a  sharp 
spoon,  and  the  skin  forming  the  margins  of  the  sinuses  excised.  The 
cavity  in  the  bone,  the  sinuses,  and  the  surrounding  skin  are  now 
thoroughly  cleansed  with  hot  carbolic  solution  (i  in  30)  or  biniodide 
of  mercury  solution  (i  in  looo),  the  flap  replaced  and  sutured,  and  the 
wound  dressed.  In  a  few  cases  thus  treated,  where  the  attempt  at 
rendering  the  wound  aseptic  has  been  successful,  rapid  healing  by 
organisation  of  blood-clot  may  take  place. 

A  further  attempt  may  be  made  to  promote  primary  union,  where 
either  the  old  operation  or  the  above  modification  has  been  performed, 
by  the  use  of  decalcified  cancellous  hone.  The  success  of  this  plan 
depends  entireh^  upon  the  production  of  an  aseptic  wound.  Every 
effort  must  therefore  be  made  by  thorough  curetting,  and  cleansing 
with  antiseptics,  to  attain  this.  The  decalcified  bone  is  introduced  in 
small  pieces  together  with  sterilised  iodoform  until  the  cavity  is  filled. 
The  wound  is  now  closed  by  suturing  the  periosteum,  and  then  the  skin 
if  the  old  operation  has  been  performed,  or  by  replacing  the  flap  if  the 
osteo-plastic  method  has  been  adopted.  Primary  union  will  only  take 
place  if  asepsis  has  been  obtained ;  if  not,  suppuration  will  occur,  when 
the  cavity  will  probably  have  to  be  cleared  out  and  made  to  heal  from 
the  bottom  by  granulation. 

Two  questions  with  regard  to  sequestrotomy  require  to  be  alluded 
to — viz.,  that  of  performing  early  sub -peri  osteal  resection — i.e.,  as 
soon  as  the  bone  is  dead,  and  before  any  shell  of  new  bone  has  formed 
around  it,  and  that  of  amputation. 

Early  Sub-periosteal  Resection. — Mr.  Holmes  (Sun/ical  Treatment 
of  Cliildren's  Diseases,  p.  385  j  has  discussed  this  question,  and  given  the 
following  advantacjes  and  disadvantages  :  "  The  advantages  of  sub- 
periosteal resection  of  the  shaft  of  the  bone  over  the  expectant  treat- 
ment are:  (i)  That  it  takes  away  what  is  a  source  of  very  acute  and 
dangerous  constitutional  irritation,  and  (2)  that  it  avoids  the  embarrass- 
ment of  future  operations,  and  the  tediousness  of  the  convalescence 
which  follows  on  the  invagination  of  a  large  sequestrum.'"  The  chief 
draidmcJi.  is  the  risk  of  more  or  less  shortening. 

The  certainty  of  shortening  here,  although  the  fibula  is  present  to 
act  as  a  stay,  to  prevent  oxvy  approximation  of  the  ankle  to  the  knee,  is 
a  most  serious  drawback,  and  when  coupled  with  the  fact  that  the 
patients  who  would  be  submitted  to  early  sub-periosteal  resection  are 
often  onl}^  just  recovered  from  a  very  prostrating  illness,  seems  to  me 
to  be  strongly  against  it  in  most  cases. 

Question  of  Amputation. — The  following  are  some  of  the  conditions 
which  will  call  for  this  operation  :  (i)  When  the  patient's  vitality  is  so 
low  as  to  be  unable  to  repair  the  wound  of  an  early  sub-periosteal 
resection,  or  to  stand  the  tax  upon  it  of  the  expectant  treatment ; 
(2)  When  the  epiphyses  are  perforated,  and  the  knee  or  ankle  (espe- 
cially if  both  are  affected)  are  involved ;  (3)  If  a  condition  of  chronic 
septicgemia  is  present  ;  (4)  If  the  general  health,  from  the  presence  of 
phthisis,  lardaceous  disease,  or  syphilis,  is  much  impaired. 


TREATMENT  OF  COMPOUND  FRACTURES.  679 


TREATMENT   OF   COMPOUND   FRACTURES.* 

The  following  special  points  for  consideration  arise  here — viz.,  (i) 
The  reduction  of  protrviding  fragments  and  the  treatment  of  splinters ; 
(2)  The  treatment  of  the  -wound  ;  (3)  Complications ;  (4)  The  question 
of  amputation. 

(i)  Protrusion  of  Fragments. — It  is  usually  the  upper  one  which  pro- 
trudes. The  difficulty  of  reduction  is  in  proportion  to  the  obliquity  of 
the  fracture,  the  length  of  the  protruding  bone,  and  the  amount  of 
spasm.  The  wound  having  been  freely  enlarged,  an  attempt  must  be 
made  b}"  extension  and  rotation  to  bring  the  fragments  into  accurate 
apposition.  This  will  often  be  facilitated  by  means  of  a  strong  elevator 
inserted  between  the  fragments,  and  used  as  a  lever.  Division  of  the 
tendo-Achillis  or  possibly  of  other  tendons  may  also  be  found  necessary 
before  satisfactory  reposition  can  be  accomplished.  Failing  all  these, 
part  of  the  bone  must  be  removed  with  a  narrow-bladed  saw  (Adams' 
osteotomy  saw  will  be  found  very  useful),  care  being  taken  to  separate 
the  periosteum  first,  and  to  protect  the  soft  parts  with  a  blunt  dissector 
passed  under  the  bone  and  by  retractors.  If  the  bone  is  splintered,  some 
judgment  is  required  as  to  what  pieces  to  remove.  Those  which  are  still 
adherent  by  their  periosteum  should  be  left.  Those  completely  torn 
away  must  be  removed,  whether  they  carry  their  periosteum  or  not. 
As  to  a  third  set  partly  adherent,  partly  not,  these,  as  a  rule,  partially 
die  in  proportion  to  the  injury  to  their  periosteum,  and  keep  up  for  a 
long  time  irritation,  and  delayed  union  with,  perhaps,  suppuration.  &c. 
They  must,  therefore,  as  far  as  practicable,  be  removed.  If  after  re- 
duction it  is  found  that  there  is  any  considerable  tendency  to  the  repro- 
duction of  the  deformity,  the  fragments  must  be  fixed  either  by  means 
of  silver  wire,  steel  screws  as  suggested  by  Mr.  W.  A.  Lane,  or  Park- 
hill's  clamp  (vide  p.  631),  the  choice  between  these  methods  depending 
upon  the  conditions  present  and  the  practice  of  the  surgeon  operating. 

(2)  In  the  treatment  of  the  vouncl  the  one  great  object  is  to  convert 
the  fracture  as  soon  as  possible  into  a  simple  one.  In  a  few  cases, 
sealing  a  small,  clean  cut  wound  at  once  with  dry  gauze,  and  collodion 
and  iodoform,  or  tinct.  benz.  co.,  may  be  sufficient.  But  in  those  cases, 
common  enough  in  large  hospital  practice,  where  the  wound  is  extensive 
and  lacerated,  and  accompanied  by  great  contusion  of  the  soft  parts, 
with  abundant  blood  extravasation,  with  much  connninution  of  frag- 
ments and  injury  to  the  periosteum,  or  where  the  fracture  is  complicated 
with  a  dislocation,  the  following  method  will  be  found  to  give  the  best 
results. 

While  an  ansesthetic  is  given,  the  whole  limb  is  thoroughly  cleansed 
with  turpentine,  hot  soap  and  water,  and  warm  i  per  cent,  lysol  solu- 
tion. The  vv'ound  having  been  freely  enlarged  and  all  recesses  well 
opened  up,  and  any  portions  of  ragged  skin  and  muscle  trimmed  off. 
the  blood-clot  is  washed  away  and  the  whole  surface  of  the  wound 
thoroughly  rubbed  over  with  swabs  soaked  in  hot  carbolic  solution 
(i  in  30)  or  biniodide  of  mercury  (i  in  looo).     The  fragments  are  now 

*  From  the  frequency  with  which  these  occur  in  the  leg  this  subject  will  be  treated 
here.  The  account  is  taken  largely  from  the  article  "  Fractures,"  Sijd.  of  Surg.,  vol.  i. 
p.  421,  which  I  re-wrote  in  1882. 


68o  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

reduced  and  fixed  as  already  described  (vide  sup-a),  and  counter  punc- 
tures made  for  drainage  as  may  be  found  necessary.  All  lifemorrliage 
being  now  arrested,  and  an}'  torn  nerves  pared  and  sutured,  the  re- 
cesses of  the  wound  are  dried  with  sponges  on  holders ;  powdered 
iodoform*  is  then  dusted  in,  dressings  of  carbolised  iodoform  or  cyanide 
gauze  applied,  and  the  limb  put  up  either  in  a  back  and  two  side  splints, 
or,  according  to  Mr.  Croft's  directions,  in  plaster  of  Paris.  Of  the  two 
I  prefer  the  former,  in  severe  cases,  for  the  first  week  :  infrequent 
dressings,  wherever  practicable,  are  most  essential. 

(3)  ComplicaAions. — My  space  will  only  allow  me  to  enumerate  these. 
They  are  local  and  general.  The  former  include  pruritus,  vesicles, 
ecchymosis,  suppuration,  oedema,  phlebitis,  gangrene,  ostitis,  caries, 
necrosis,  muscular  spasms,  dislocations,  and  implication  of  a  neigh- 
bouring joint.  The  general  complications  are  such  as  are  common  to 
all  injuries — viz.,  traumatic  fever,  delirium,  erysipelas,  septicaemia, 
pyaemia,  hectic,  tetanus,  jaundice,  and  retention  of  urine ;  in  older 
patients  a  tendency  to  hypostatic  congestion  and  broncho-pneumonia, 
and  finally,  in  a  few  cases,  pulmonary-  fat-embolism. 

(4)  Question  of  Amputotioii. — The  following  are  amongst  the  condi- 
tions requiring  primary  amputation:  (i)  When  a  limb  is  torn  off  b}*  a 
cannon-ball,  a  portion  of  shell,  or  by  machinery.  (2)  When  the 
division  of  the  soft  parts  is  nearly  complete,  except  in  the  case  of  a 
clean  cut  across  the  phalanges,  metacarpus,  or  metatarsus ;  even  the 
forearm  may  occasionally  be  saved  under  similar  circumstances. 
(3)  When  there  is  much  actual  loss  of  soft  parts,  as  when  one  side  of 
a  limb  is  torn  away,  or  the  skin  is  extensiveh'  peeled  off.  (4)  When, 
with  or  without  great  comminution  of  the  bones,  there  is  much  bruising 
and  laceration  of  the  soft  parts,  with  protrusion  of  muscular  bellies,  and 
extensive  tearing  up  of  deep  planes  of  areolar  tissue.  (5)  In  some 
cases  when  the  principal  artery  and  nerves  of  the  limb  are  both  divided, 
thus,  in  the  case  of  the  lower  limb,  primarj^  amputation  will  usually  be 
required.      (6)    In    certain   cases    of  severe    haemorrhage,  primary    or 

This  most  valuable  drug  is  not  sufficientl}'  used  in  these  cases.  I  may  briefly 
mention  three  cases  in  which  limbs  were,  I  think,  saved  by  it.  One  was  a  very  severe 
compound  fracture  of  the  femur  in  a  man,  aged  46,  who  fell  twenty-two  feet  on  to  the 
banks  of  the  Thames,  striking  a  stone  buttress  as  he  went  down.  I  saw  him  about  an 
hour  after  the  accident.  The  fragments  were  much  displaced  and  overlapping,  the 
lower  one  being  also  split  vertically,  but  not  so  far  as  the  knee-joint.  The  ends  of 
both  were  bare,  and  the  vastus  externus  and  hamstrings  were  lacerated,  the  injury 
having  been  made  greater  by  the  patient  having  been  lifted  off  the  mud  on  to  which 
he  fell  into  a  boat,  and  then  into  a  cab.  Ether  having  been  given,  the  external 
wound,  through  which  the  vastus  externus  protruded,  was  freely  enlarged,  and  its 
recesses  well  washed  out  with  i  in  30  carbolic  acid  solution,  as  advised  above.  About 
5j  of  iodoform  was  then  carried  down  right  between  the  fragments  by  means  of  the 
finger  and  a  narrow  spatula,  and  two  large  drainage-tubes  inserted.  An  aseptic  result 
was  secured  from  the  first  and  maintained,  throughout,  by  the  dresser  (Mr.  J.  H. 
Lister),  the  man  making  an  excellent  recovery.  The  second  case  was  that  of  a  com- 
pound comminuted  fracture  of  the  leg,  with  wound  of  the  anterior  tibial  artery 
(mentioned  at  p.  668).  The  third  occurred  in  a  boy  with  compound  separation  of  the 
lower  epiphysis  of  the  tibia,  in  which  two  inches  of  the  protruding  diaphysis  were 
removed.  The  case  did  so  well  after  the  introduction  of  iodoform  and  the  other 
precautions  already  given,  that  the  first  dressings  were  not  removed  till  the  eighth 
dav.  and  the  lad  recovered  with  an  excellent  limb. 


treat:mext  of  compound  FEACTURES.  68 1 

secondary.  On  this  subject  I  must  refer  my  readers  to  the  remarks 
ah'eady  made  at  p.  66l.  (7)  Some  cases  of  compound  fracture  of 
large  joints — viz.,  when  one  bone  is  shattered  or  more  than  one  is 
broken ;  when  there  is  much  laceration  of  the  ligaments ;  when,  in 
addition  to  comminution  of  the  bones,  there  is  much  contusion  of  the 
soft  parts,  especially  if  complicated  with  division  of  an  arter}- ;  when' the 
foreign  body  which  has  caused  the  fracture  remains  in  the  joint,  or, 
projecting  into  it  from  its  bed  in  the  bone,  cannot  easily  be  removed,  or 
when  there  is  much  damage  to  the  articular  surfaces.  It  Mall  be  under- 
stood that  all  these  forms  of  injury  are  most  fatal  when  affecting  the 
knee  or  hip  ;  in  dealing  with  other  joints  much  greater  latitude  may  be 
xdlowed. 

Finally,  before  deciding  on  amputation,  the  sui-geon  must  take  into 
consideration,  in  addition  to  the  above  points  which  concern  the  fracture 
itself,  any  general  information  to  be  gained  about  the  patient  himself. 
Thus,  the  age,  constitution,  habits,  any  sign  of  visceral  disease,  and 
the  appearance  of  the  patient,  are  all  points  of  material  importance  in 
•coming  to  a  decision  between  amputation  and  an  attempt  to  save  the 
limb.  Thus,  to  make  my  meaning  clearer,  there  are  no  more  anxious 
•cases  than  severe  compound  fractures  in  dwellers  in  large  towns,  who 
are  past  middle  life,  flabbily  fat,  with  dilated  venules  about  the  cheeks 
xind  nose,  whose  conjunctivee  are  slightly  jaundiced,  the  urine  of  low 
specific  gravity  and  perhaps  albuminous.*  The  surgeon  must  here  bear 
in  mind  that  saving  the  patient's  life  is.  after  all.  of  more  importance 
than  the  preservation  of  his  limb. 

In  performing  amputation  in  these  cases  of  compound  fracture  it  is 
ahvavs  to  be  remembered  that  the  injury  is  not  so  localised  as  would 
appear  from  the  surface ;  thus,  in  compound  fracture  of  the  leg  there  is 
often  extensive  loosening  of  the  skin  from  the  deep  fascia,  and  extrava- 
sation of  blood  into  the  deep  planes  of  connective  tissue  for  some 
distance  above,  the  knee-joint  being  perhaps  full  of  blood,  and  its 
•cartilages  bruised.  In  such  cases,  if  amputation  be  performed  just 
above  the  injury,  sloughing  and  separation  of  the  flaps  will  inevitably 
follow.  On  the  other  hand,  in  cases  of  severe  compound  fracture  of  the 
thigh,  where  amputation  is  required  high  up,  it  will  be  found  bettei 
practice  to  amputate,  in  part  at  least,  through  injured  tissues.! 

If.  in  addition  to  the  fracture,  there  are  serious  injuries  to  other 
organs,  immediate  amputation  is  useless  or  injurious.  The  only  chance 
■of  recovery  here  is  afforded  by  secondary  amputation  after  the  early 
dangers  are  past. 

Secondary  amputation  may  be  required  for  jirofuse  suppuration  with 
hectic,  for  gangrene,  or  uncontrollable  haemorrhage.  The  decision 
must  here  be  made  according  to  the  needs  of  each  case.  The  surgeon 
must,    if    possible,    wait    till    the    traumatic   fever    and    constitutional 

*.Note  will  also  be  taken  of  the  occupation,  as  in  brewers'  draymen  and  commercial 
travellers. 

f  Thus,  in  the  case  of  a  young  railway  porter,  whose  thigh  was  smashed  by  a 
railway  accident  at  Epsom,  I  performed  amputation  at  the  level  of  the  lesser 
trochanter,  in  preference  to  the  hip-joint.  The  damaged  flaps  sloughed,  as  I 
■expected,  but  the  patient  made  a  good  recovery,  after  the  removal  of  some  dead  bone. 
The  precautions  already  given  against  shock  (p.  584)  will,  of  course,  be  taken  in 
these  cases. 


682  OPERATIOXS  OX  THE  LOWER  EXTREMITY. 

disturbance  are  subsiding,  till  the  temperature  has  begun  to  fall, 
and  till  all  redness,  erysipelas,  and  sloughing  have  ceased.  On  the 
other  hand,  if  the  operation  be  deferred  till  the  powers  of  the  patient 
are  running  down  from  profuse  suppuration  and  hectic,  and  till 
confirmed  asthenia  has  set  in,  the  period  of  performing  it  will,  very 
probably,  have  passed  a\xaj. 

At  a  still  later  period  the  operation  may  be  desired  by  the  patient,  if, 
in  consequence  of  non-union,  incurable  deformity,  or  tedious  bone 
disease,  the  limb  has  become  an  encumbrance  to  him.  Some  of  these 
conditions  may,  of  course,  be  treated  b}-  resection,  osteotomj^,  &c. 


OPERATIVE    TREATMENT    OF    SIMPLE    FRACTURES. 

Since  Mr.  W.  A.  Lane  (Clin.  Soc.  Trans.,  vol.  xxvii.)  first  brought 
forward  the  proposition  that  certain  simple  fractures  of  the  leg  should 
be  treated  by  open  incision  and  fixation  of  the  fragments  by  mechanical 
means,  considerable  attention  has  been  drawn  to  this  subject.  Although 
opinions  are  still  much  divided,  there  can  be  no  doubt  that  under  certain 
circumstances  such  treatment  is  the  best.  The  truth  of  Mr.  Lane's 
original  contention,  that  certain  of  these  fractures  could  not  be  satis- 
factorily reduced  by  any  means  short  of  operation,  was  certainly  not 
full}'  realised  until  the  perfection  of  radiographic  methods  made  it 
possible  to  accurately  observe  the  efiects  of  extension  and  the  other 
means  usually  employed  in  the  treatment  of  such  cases. 

The  radiograph  has,  however,  demonstrated  the  fact  that  repeated 
attempts  at  reduction  by  extension  and  manipulation,  however  skilfully 
conducted,  will  fail  to  produce  a  satisfactory  result  in  certain  cases  of 
spiral  and  oblique  fractures  of  the  tibia.  A  free  incision  renders  it 
possible  to  overcome  the  displacement,  first  by  permitting  the  removal 
of  the  effusion  and  blood-clot  upon  which  the  displacement  is  largely 
dependent,  and  second  by  allowing  of  direct  leverage  of  the  fragments 
in  the  required  direction. 

The  chief  objection  is  the  increased  risk  to  the  patient,  in  other  words 
the  dangers  of  wound  infection.  Although  the  risk  of  converting  a 
simple  into  a  compound  fracture,  when  all  the  necessary  precautions  can 
be  taken,  and  when  the  surgeon  and  his  assistants  are  thoroughly 
conversant  with  the  details  of  aseptic  surgery,  is  a  comparatively  small 
one,  yet  it  must  be  borne  in  mind  that  the  conditions  here  are  not  all 
that  can  be  desired  for  the  performance  of  an  aseptic  operation.  For 
it  must  be  remembered,  in  the  first  place,  that  the  skin  is  often  in  such 
a  delicate  and  injured  condition  as  to  render  its  proper  preparation  far 
from  easy,  and  in  the  second  place  that  the  operation  is  performed  upon 
tissues  already  much  damaged,  and  hence  peculiarly  liable  to  infection. 
The  risk  should,  on  the  other  hand,  compare  favourably  with  that 
incurred  in  operating  upon  a  recent  fracture  of  the  patella,  since  this- 
involves  the  opening  of  the  knee-joint. 

Before  deciding  to  operate  upon  any  given  case,  the  following  points 
should  be  carefully  considered  : — (i)  Affe. — Only  in  a  young,  healthy 
patient,  with  a  prospect  of  a  long  and  active  life,  should  operation  be 
advised. 

(2)  Sex. — This  treatment  will  very  rarely  be  necessary  in  women,  as. 
in  them  the  limb  will  not  be  required  to  bear  heavy  strains. 


OPERATIVE  TREATMENT  OF  SIMPLE  FRACTUEES.  683 

(3)  Ocnq)ation. — This  is  of  great  importance,  for  a  sufficiently  good 
result  Avill  be  usually  obtained  by  means  of  splints,  massage,  etc., 
unless  the  occupation  is  a  laborious  one  necessitating  the  putting 
of  great  strains  upon  the  fractured  limb. 

(4)  General  Jtealth,  hahits,  etc. — The  bearing  of  intemperance,  renal 
disease,  diabetes,  etc.,  will  be  considered  here. 

Where  the  above  conditions  are  favourable  to  operation — where  the 
surroundings,  as  regards  the  proper  carrying  out  of  an  aseptic  operation, 
are  satisfactorj- — and  where  repeated  attempts  controlled  by  radiography 
have  failed  to  satisfactorily  correct  the  displacement — operation  should 
be  undertaken. 

The  cases  thus  recjumng  operative  interference  will  be  as  follows  : — 

1 .  Certain  cases  of  spiral  fracture  of  the  tibia. 

2.  A  few  instances  of  oblique  fracture  of  the  tibia. 

3.  Certain  cases  of  Potts  fracture. 

Operation. — The  skin  of  the  whole  leg  must  be  careful!}^  shaved, 
then  gently  cleansed  with  hot  water  and  soap,  ether,  and  then  a  i  in 
500  solution  of  biniodide  of  mercury  in  methylated  spirit,  and  a 
dressing  of  bicyanide  gauze  applied  for  twenty-four  hours. 

After  the  patient  has  been  anassthetised  the  skin  should  be  again 
cleansed  with  the  biniodide  of  mercury  or  other  antiseptic  solution. 
A  very  free  longitudinal  incision  is  no\A'  made  over  the  seat  of  fracture 
down  to  the  bone,  and  the  soft  parts  carefully  separated  sufficiently  to 
thoroughly  expose  the  fragments. 

All  hsemorrhage  must  now  be  arrested,  and  the  blood-clot  around  the 
seat  of  fracture  removed  by  sponging  or  irrigation,  any  jagged  or  much 
lacerated  muscular  tissue  being  snipped  away  with  scissors.  The  next 
step  is  the  reduction  of  the  di'^placernent,  and  is  often  extremely  difficult. 
While  suitable  extension  is  made  by  assistants  pulling  upon  the  upper 
part  of  the  leg  and  the  foot,  the  surgeon  prises  the  fragments  into  their 
correct  position  by  means  of  a  strong  elevator  and  lion  forceps,  any 
comminuted  fragments  being  at  the  same  time  accurately  fitted  into 
their  proper  positions.  While  the  corrected  position  is  maintained  by 
lion  forceps  and  extension,  the  fixation  of  the  fragments  is  carried  out. 
The  means  of  accomplishing  this  will  depend  upon  the  shape  of  the 


Fig.  280. 


feUl **«^4^#Wtel*la 


<4«jaa?»HHt£ai^"  •-  --J^ 


fragments  and  the  choice  of  the  surgeon.  Silver  wire,  screws,  plates, 
the  Parkhill  clamp  (p.  631),  and  a  number  of  other  appliances  have 
been  made  use  of  by  different  surgeons.  Of  these  strong,  pliable  silver 
wire  is  certainly  the  most  generalh^  useful,  and  will  be  found  efficient 
for  nearly  all  cases.  The  Parkhill  clamp  has,  however,  given  very 
satisfactorv  results    in   a  number  of  cases,   and  is  w^ll  worthv  of  an 


684  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

extended  trial ;  the  chief  objections  to  it  are  its  costliness  and  the 
resulting  open  wound. 

If  screws  are  used  they  should  have  a  wide  thread,  the  best  being 
those  recommended  by  Mr.  Lane  {vide  Fig.  280),  which  have  a  small 
head,  and  taper  but  slightly. 

Having  decided  upon  the  means  to  be  employed,  the  surgeon  now 
proceeds  to  drill  the  bones  in  whatever  direction  is  most  suitable  for  the 
particular  case.     The  drills  should  be  sharp  and  well  tempered,  those 

Fig.  281. 


made  by  Weiss  for  Mr.  Lane  being  as  suitable  as  any.  If  a  screw  is  to 
be  inserted  the  drills  used  should  be  a  size  smaller  than  the  screw  ;  the 
upper  part  of  the  hole  must  then  be  enlarged  with  a  reamer  (Fig.  281) 
of  the  same  size  as  the  shank  of  the  screw ;  and  a  counter-sink  should 
also  be  made,  for  the  head  of  the  screw,  with  a  burr.  The  fragments 
having  been  securely  fixed,  the  wound  is  well  dried,  and  then  sutured, 
a  small  drain  being  left  in  for  twenty-four  hours  if  there  is  much 
bruising.     Dressings  and  a  splint  are  then  applied. 


EXCISION    OF    VARICOSE    VEINS. 

This  method,  as  old  as  the  times  of  Celsus,  and  one  which  fell  into 
disuse  from  the  risks  of  j^ygemia,  &c.,  was  revived  Mith  safety  some 
years  ago  by  Mr.  Davies-Colley  (Gai/s  Hosp.  Reports,  1875,  p.  431), 
when  Lord  Lister  had  shown  how  the  old  dangers  might  be  avoided. 

Indications. — Safe  as  this  operation  has  been  made,  it  is  to  be 
recommended  with  caution  owing  to  the  great  risk  of  recurrence.  If 
this  operation  is  largely  employed,  and  the  cases  are  carefully  watched, 
it  will  be  found  after  some  years  that  the  amount  of  permanent  benefit 
ensured  is,  in  many  cases,  very  small. 

Before  the  varices  are  removed  it  must  be  ascertained  that  the  better 
supported  deep  veins,  through  which  it  is  intended  that  the  blood  shall 
largely  return  after  the  superficial  ones  are  obliterated,  are  healthy.* 
The  cases  best  suited  for  operation  are  :  (i)  Where  only  one  vein-trunk 
is  involved,  at  one  or  two  definite  parts  of  its  course.  (2)  Where  both 
saphenous  veins  are  involved,  but  again  definitely  and  localh'.  The 
more  the  varices  are  longitudinal,  the  more  they  lie  in  the  lines  of  the 
trunk,  the  more  longitudinal  incisions  will  sufiice,  the  more  satisfactory 
the  operation  and  the  better  and  more  lasting  the  results.  On  the  other 
hand,  where  the  enlargement  is  bilateral  and  general,  where  numerous 
communicating  veins  between  the  trunks  are  enlarged,  where  the  venous 

♦  A  full,  tumid  condition  of  the  calves  points  to  a  varicose  state  of  the  sural  veins, 
and  is  against  operation. 


EXCISION  OF  VAEICOSE   VEINS. 


685 


Fig.  2S2. 


radicles  are  becoming  dilated  and  their  ramifications  plexiform,  the 
more,  in  short,  that  the  disease  shows  signs  of  being  a  general  one,  the 
more  will  the  result  be  disappointing.  Finally,  the  soft  parts  near  the 
varices  should  be  in  a  healthy  condition,  free  from  dermatitis,  and  thus 
capable  of  being  rendered  aseptic,  and  of  uniting  quickly  afterwards. 
In  the  two  following  conditions  operation  may  occasionally  be  called 
for.  though  the  conditions  required  above  are  not  now  always  present. 
is)  Where  many  varices  exist,  but  one  or  two  are  especially  trouble- 
some. (4.)  Where  many  varices  exist,  but  one  especially  is,  definitely, 
the  cause  of  an  ulcer  troublesome  to 
heal,  and  perhaps  already  the  source 
of  dangerous  bleeding  (Fig.  282J. 

Operation. — The  skin  of  the  limbs 
should  be  shaved  and  prepared  the  day 
before  the  operation,  and  the  course  of 
the  varicose  veins  then  marked  out  in 
the  following  manner.  The  cleaning  of 
the  skin  having  been  completed,  the 
patient  should  stand  in  order  to  distend 
the  veins,  the  outlines  of  which  are  then 
marked  on  the  skin  with  carbolic  fuchsin 
solution,  applied  either  with  a  camel- 
hair  brush  or  a  match-stick.  An  anti- 
septic dressing  is  then  applied  and  left 
in  place  until  the  time  of  operation. 
The  patient  having  been  anfesthetised. 
and  the  dressings  removed,  longi- 
tudinal incisions  are  made  over  the 
chief  varices — where  the  trunk  is  merely 
dilated  segments  about  three  inches 
long  should  be  removed — the  subcu- 
taneous fat  opened,  the  vein  exposed 
by  light  touches  of  the  knife  of  the 
whole  of  the  extent  which  it  is  proposed 
to  excise,  a  fine  ligature  is  then  tied 
round  the  lower  end,  the  vein,  held  in 
dissecting  forceps,  is  cut  through  just 
above  the  ligature,  dissected  out,  any 
branch-veins  clamped  with  Spencer 
Wells's  forceps,  until  the  upper  ex- 
tremity of  the  wound  is  reached,  when 
another  ligature  is  tied  round  the  vein,  and  the  varix  removed.  Any 
clamped  points  are  then  tied,  and  the  wound  closed  by  a  trusted  assistant, 
while  the  operator  proceeds  to  deal  with  another  vein.  I  will  venture 
to  commend  the  following  cautions  to  my  younger  readers,  (i)  The 
strictest    aseptic    precautions    Avill,    of    course,    be    taken    throughout. 

(2)  Care  should  be  taken  in  exposing  the  varix ;  though,  from  its 
])osition,  this  may  appear  to  be  part  of  a  main  trunk,  it  may  only  over- 
lap this,  which  ma}'  need  no  interference  (Davies-Colley.  loc.  supra  cit.). 

(3)  Every  bleeding-point  should  be  carefully  tied,  otherwise  tension  will 
occur,  iindermining  of  the  edges  of  the  wound  by  blood-clot,  suppuration 
and  delayed  healing.     (4)  TJie  close  proximity  of  the  nerve-trunks  must 


Case  of  varicose  internal  saphena 
veiu  with  dermatitis  and  ulceration 
below.  From  the  ulcer  severe 
h»morrbaKe  had  occurred.  I  saw 
the  woman  three  jears  after  the 
operation  on  the  varicose  veins,  and 
she  remained  well,  but  I  have  lost 
sight  of  her  since. 


686  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

be  remembered.  Hasty  operating  may  easily  lead  to  removal  of  part  of 
one  of  these.  This  is  only  justifiable  when  varices  are  being  removed 
from  the  leg  of  a  patient  who  complains  bitterly  of  the  pain  caused 
about  either  malleolus  by  a  clump  of  plexiform  dilated  varices,  and 
where  it  is  doubtful  if  the  removal  of  the  varices  above  will  relieve  this. 
(5)  The  ligatures  used  should  be  fine  and  thoroughly  prepared,  other- 
wise they  will  work  out  vexatiously,  a  result  rendered  the  more  probable 
if  the  patient  persists  in  getting  about  too  early. 


CHAPTER  VII. 
OPERATIONS  ON  THE  FOOT. 

LIGATURE  OP  THE  DORSALIS  PEDIS.— SYMES  AMPUTA- 
TION.—ROUX'S  AMPUTATION.— PIROGOFE'S  AMPUTA- 
TION.—SUB-ASTRAGALOID  AMPUTATION.  —  EXCISION 
OF  THE  ANKLE.— ERASION  OF  THE  ANKLE.— EXCISION 
OF  BONES  AND  JOINTS  OF  THE  TARSUS. — EXCISION 
OF  ASTRAGALUS.— EXCISION  OF  OS  CALCIS— MORE 
COMPLETE  TARSECTOMY  FOR  CARIES.  —  REMOVAL 
OF  WEDGE  OF  BONE.  AND  OTHER  OPERATIONS  FOR 
INVETERATE  TALIPES.— CHOPARTS  AMPUTATION. 
— TRIPIERS  AMPUTATION.— AMPUTATION  AT  META- 
TARSO-PHALANGEAL  JOINT.— AMPUTATION  OF  THE 
TOES. 

LIGATURE   OF  THE   DORSALIS  PEDIS   (Fig.   283). 

Indications. — ^'eiy  rare.  (i)  Wounds.  (2)  Together  with  the 
posterior  tibial  in  the  lower  third,  for  ha?morrhage  from  punctured 
wounds  of  the  sole  resisting  other  treatment.  (3)  For  some  vascular 
gro^^'ths  of  the  foot. 

Line. — From  the  centre  of  the  ankle-joint  to  the  upper  part  of  the 
first  interosseous  space. 

Guide. — The  above  line  and  the  adjacent  tendons  of  the  great  and 
second  toe. 

Relations:  Ix  Front. 

Skin,  fascije;  branches  of  saphenous  veins,  and  of  musculo- 

cvitaneous  and  anterior  tibial  nerves. 
A  special  deep  fascia  continuous   with  the  sheaths  of  the 

adjacent  tendons. 
Extensor  brevis  (innermost  tendon). 

Outside.  Inside. 

Vein.  .  Dorsalis  pedis  A'ein. 

Anterior  tibial  nerve.  artery.  Extensor  longus  pollicis. 

Extensor  longus  digitorum. 

Behind. 

Astragalus  ;  scaphoid  ;  internal  cuneiform. 


688 


OPERATIONS  ON  THE  LOWER  EXTREMITY. 


Operation  (Fig.  283). — The  foot  having  been   cleansed,  an  incision 
about  an  inch  and  a  lialf  long  is  made  in  the  line  of  the  artery,  in  the 
lower  part  of  its  conrse,  commencing  abont  an 
Fig.  283.  inch  and  a   half  below  the  ankle-joint.     Skin 

and  fasciae  being  cnt  through,  and  any  superficial 
veins  tied  with  chromic  gut  or  drawn  aside, 
one  of  the  long  extensors  is  found  (its  sheath  is- 
not  to  be  opened),  and  the  strong  fascia  given 
off  from  them  opened.  If  the  extensor  brevi& 
cross  the  artery  at  this  spot  it  must  be  dra^'n 
aside.  The  ligature  should  be  passed  from, 
without  inwards. 

SYME'S  AMPUTATION. 

(Figs.  284  and  287.) 

An  amputation  at  the  ankle-joint  by  a  heel- 
flap,  with  removal  of  the  malleoli. 

Operation. — Haemorrhage  having  been  con- 
trolled, any  sinuses  present  scraped  out,  the 
foot  bandaged,*  and  held  at  right  angles  to  the 
leg,  the  surgeon,  standing  a  little  to  the  right, 
but  so  as  easily  to  face  the  sole,  makes,  with  a 
short,  strong  knife,  an  incision  (in  the  case  of 
the  left  foot)  from  the  tip  of  the  external 
malleolus  to  a  point  half  an  inch  below  f  the 
internal  one,  this  incision  not  going  straight 
across  the  sole  as  in  Pirogofi^s  ampiitation,  but 
pointing  a  little  backwards  towards  the  heel.j 
The  horns  of  this  incision  are  then  joined  by 
one  passing  straight  across  the  joint, §  and 
by  the  innermost  tendon  of  severing  everything  at  once  down  to  the  ankle- 
the  short  extensor.  joint.     The  foot  being  now  strongly  bent  down- 

wards, the  lateral  ligaments  are  severed,  and 
the  joint  thus  full}^  opened.  The  foot  being  slightly  twisted  from  side 
to  side,  the  soft  parts  on  either  side  are  carefully  divided,  especial  pre- 
cautions being  taken  on  the  inner  side  to  cut  the  posterior  tibial  artery 
as  long  as  possible  (to  ensure  getting  below  the  internal  calcanean)  and 
not  to  prick  it  afterwards. 


The  dorsalis  pedis  (too 
much  of  the  artery  is  shown 
cleaned)  is  seen  lying  between 
the  extensor  longus  pollicis 
and    digitorum,   and    crossed 


*  So  as  to  give  a  grip,  and  also  to  prevent  the  assistant's  hands  from  being  septic 
when  he  supports  the  stump  a  little  later. 

t  The  directions  usually  given  are  to  go  behind  this  point  as  well  as  below  it,  but 
by  following  the  above  course  the  posterior  tibial  is  more  likely  to  escape  section 
before  its  time,  and  the  flap  will  be  found  sufficiently  symmetrical. 

J  If  the  foot  is  small,  and,  still  more,  if  the  parts  on  the  dorsum  are  damaged,  the 
plantar  incision  should  run  straight  across.  On  the  other  hand,  the  more  prominent 
the  heel,  the  more  should  the  flap  point  backwards.  This  will  facilitate  turning  the 
flap  over  the  heel. 

§  Or  with  very  slight  convexity.  If  anything  of  a  flap  is  made  here,  the  operator 
is  liable  to  get  away  from  the  joint  and  cut  into  the  neck  of  the  astragalus.  More- 
over, the  parts  are  not  well  nourished,  especially  if  sinus-riddled  or  undermined. 


SYME'S   AMPUTATIOX. 


689 


Fig.  284. 


The  foot  being  still  more  depressed,  the  upper  non-articular  surface 
of  the  OS  calcis  comes  into  view,  and  then  the  tendo-Achiilis.  This  is 
severed,  and  the  heel-flap  next  dissected  off  the  os  calcis  from  above 
downwards,  special  care  being  taken  to  cut  this  flap  as  thick  as 
possible,  not  to  score  or  puncture  it,  but  rather 
to  peel  it  off"  the  bone  with  the  left  thumb-nail 
kept  in  front  of  the  knife,  aided  by  touches  of 
this.* 

The  foot  having  been  removed,  the  soft  parts 
are  carefulh"  cleared  off"  the  malleoli,  and  a  slice 
of  the  tibia  sufficiently  thick  to  include  these 
prominences  removed.  This  slice  should  in  any 
case,  to  avoid  shortening,  be  the  thinnest 
possible.  Prof.  Macleodt  has  recommended  to 
remove  only  the  malleoli,  leaving  the  cartilage 
on  the  under  surface  of  the  tibia.  I  have 
followed  his  advice  in  my  last  eleven  cases — in 
one,  a  private  patient  of  Gt,,  where  I  had  not  the 
carrying  out  of  the  after  treatment,  the  cartilage 
exfoliated.  The  others  were  all  younger  patients 
— in  one,  in  addition  to  the  disease  of  the  tarsus, 
active  secondary  s^'philis  was  present ;  in  all,  in 
spite  of  tubercular  sinuses  in  three  which 
required  repeated  scraping  out  (Fig.  287),  no 
exfoliation  took  place.  If  the  stump  can  be 
kept  aseptic.  Prof.  Macleod's  advice  seems  to  me 
well  worth  a  further  trial,  as  it  entails  less 
shortening  of  the  limb  and  does  away  with  the 
risk  of  septic  phlebitis,  which  may  be  brought 
about  by  opening  the  cancellous  tissue.  If,  on 
the  other  hand,  the  lower  end  of  the  tibia  is 
diseased,  it  must  be  removed  and  the  sawn 
surface  gouged  or  treated  with  a  sharp  spoon. 
If  the  cartilage  is  only  slightly  diseased,  it  may 
be  sliced  off"  with  the  knife,  and  here  and  there  treated  with  a  gouge. 

Tendons  are  now  cut  short,  sinuses  laid  open  or  thoroughly  scraped 
out,  and  the  vessels  secured.  Free  oozing  is  often  present  in  chronic 
pulpy  cases,  or  where  the  periosteum  has  been  left  in  the  heel-flap.  It 
is  best  treated  by  firm  pressure  with  dry  dressings,  and  elevation  of  the 
stump.  Drainage  having  been  provided,  the  sutures  are  inserted ; 
where  many  sinuses  have  been  present  along|  the  line  of  the  incision, 
it  is  no  good  uniting  the  wound  closely. 

*  If,  in  a  young  subject,  the  epiphysis  comes  away  in  the  heel-flap,  it  may  remain 
there  if  the  parts  are  healthy.  The  same  course  may  be  followed  with  the  periosteum, 
if  it  is  found  loose  and  peels  easily  away.  Mr.  Johnson  Smith,  when  amputating  both 
feet  for  frost-bite,  left  the  periosteum  on  one  side.  On  the  other  no  attempt  was 
made  to  save  it.  The  first  stump  was  much  larger  than  the  other,  harder,  and  more 
rounded  ;  more  like  that  of  a  PirogofE's  amputation. 

f  Brit.  Med.  Journ. ,  1869,  vol.  ii.  p.  239. 

X  Sinuses  which  have  been  scraped  out  will  give  good  drainage  if  enlarged.  If  any 
puncture  has  been  made  in  the  heel-flap,  it  should  be  utilised  for  the  same  purpose. 
Where  a  diseased  foot  has  been  long  on  a  back-splint,  the  skin  over  the  tendo-Achillis 

VOL.  II.  44 


The  parts  in  a  Syme's 
amputation  before  the 
heel-flap  is  adjusted  (left 
side).  The  bones  are 
shown  above  with  the 
extensor  tendons  and  the 
anterior  tibial  vessels,  and, 
below,  the  teudo-Achillis. 
On  the  inner  side  the 
flexor  tendons  and  the 
plantar  arteries  are  shown 
cut ;  on  the  outer  side, 
the  peronsei.  This  figure 
should  be  contrasted  with 
Fig.  290. 


690 


OPERATIONS  ON  THE  LOWEK  EXTREMITY. 


Roux's  Modification  of  Syme's  Amputation  (Figs.  285  and  286). — 
In  cases  where  a  satisfactory  heel-flap  cannot  be  obtained,  an  efficient 
substitute  can  be  got  by  a  large  internal  flap. 

The  incision  is  commenced  at  the  apex  of  the  outer  malleolus,  and 
carried  half  across  the  front  of  the  ankle-joint,  from  whence  it  should 
run  inwards  in  an  oblique  direction  over  the  astragalo-scaphoid  joint, 
then  pass,  in  a  curved  manner,  downwards  and  backwards  to  the 
middle  line  of  the  sole  of  the  foot,  and,  running  along  the  under  surface 
of  the  heel,  ascend  the  posterior  aspect  of  that  part,  and  terminate  at 
the  outer  malleolus,  where  it  commenced.  The  ankle-joint  should  be 
opened  at  its  upper  and  outer  part,  the  os  calcis  dissected  from  its 
connections,  the  malleoli  and  a  slice  from  the  articular  surface  of  the 
tibia  removed,  and  the  operation  will  be  complete.  The  shape  of  the 
flap  will  be  gathered  from  the  appearance  of  a  foot  operated  upon 
(Fig.  285). 


Koux's  amputation  at  the  aukle-joint  by  au  internal  flap.      Below  is  shown  a  foot  upon 
which  the  operation  has  been  performed.     (Smith  and  Walshaui.) 

Causes  of  Failure  after  Syme's  Amputation. — (i)  Sloughing  of 
the  heel-flap.  This  is  nearly  always  due  to  faulty  operating,  to  scoring 
or  "button-holing"  the  flap,  or  to  dividing  the  posterior' tibial  high 
up.*  (2)  Persistence  of  sinuses  and  tubercular  disease.  If,  in  spite  of 
repeated  scraping  out  (Fig.  287)  with  the  aid  of  anaesthetics,  this  condi- 
tion recurs  inveterately  and  spreads  along  the  sheaths,  the  limb  must  be 


may  be  so  thinned  that  it  is  advisable  to  make  a  counter-puncture  here  and  insert 
a  tube. 

*  If  possible,  the  cut  ends  of  the  two  plantar  arteries  should  always  be  seen,  and  not 
the  single  mouth  of  the  posterior  tibial.  In  the  former  case  the  surgeon  is  certain  that 
the  main  vessel  is  divided  below  the  internal  calcanean  branch. 


PIKOGOFF'S  AMPUTATION. 


691 


Fig.  286. 


r>V 


amputated  higher  up.  This  will,  however,  be  rarely  called  for  with 
perseverance  on  the  part  of  the  surgeon  to  treat  this  condition  as  a  kind 
of"  malignant  disease.  If"  one 
or  two  sinuses  remain,  and 
look  likely  to  persist,  scrap- 
ing out  should  be  resorted 
to  at  once.  (3)  Recurrence 
of  caries  in  the  tibia. 
(4)  Deatii  of  the  tendo- 
Achillis. 

This  rare  sequela  occurred  to 
me  in  1890.  The  patient  was  an 
aged  inmate  of  the  Camberwell 
Infirmary.  A  bluish  undermined 
patch  being  laid  open  on  the  back 
of  the  ankle  some  weeks  after  the 
amputation,  the'tendon  was  found 
to  have  died  up  to  its  junction 
with  the  calf  muscles.  After  its 
removal  the  parts  healed  soundly. 


Eoux's  amputation.     The  incisions  shown  from  the 
outer  and  the  inner  side.     (Stimson.) 


PIROGOFF'S    AMPUTATION 

(Figs.  288-291). 

An  amputation  at  the  ankle-joint,  in  which 
the  posterior  part  of  the  os  calcis  is  retained  and 
united  to  the  sawn  surface  of  the  tibia. 

Question  of  the  Value  of  this  Operation 
especially  as  compared  with  Syme's  Ampu- 
tation.— DisadcanicKjes :  These  have  been  put 
prominently  forward  b}"  Scotch  surgeons,  i .  The 
amputation  is  not  suited  for  cases  of  disease, 
except  of  distinctl}^  traumatic  origin  in  young- 
healthy  subjects.  2.  Occasionally  the  sawn  os 
calcis  fails  to  unite,  causing  either  a  kind  of 
movable  joint  or  necrosis.  3.  It  is  said  by  some 
that  the  stump  is  more  difficult  to  fit  with  an 
artificial  foot.*  The  first  two  objections  are 
undoubted,  but  I  think  that  they  are  quite  out- 
weighed by  the  Advanta/je^ :  i .  No  dissection  of 
the  heel-flap  is  needed.  2.  The  blood-supply  is 
less  interfered  with.  3.  The  stump  is  firmer  and 
more  solid.  4.  The  stump  is  longer  by  one  inch 
or  one  inch  and  a  half,  often  more.j  5-  ^^^^ 
stump  does  not  go  on  wasting,  as  is  the  case 
after    a    >S3mie's    amputation.^      6.    Dr.    Hewson 


Fig.  287. 


A  Syme's  stump  soundly 
healed  after  scraping  out  of 
sinuses  had  been  resorted 
to.  The  patient  was  sent  to 
me  by  Dr.  Fraser,  ot  Rom- 
ford, and  had  active  second- 
ary syphilis  as  well  as  ex- 
tensive caries  of  the  tarsus. 


*  Prof.  Macleod  thinks  that  the  presence  of  the  heel  is  here  "  a  great  drawback,  and 
that  the  back  of  the  heel,  not  the  firm  plantar  pad,  is  what  comes  in  contact  with 
the  ground."     See  the  remarks  p.  C94. 

t  Dr.  Hewson  (loc.  infra  cit.)  gives  the  shortening  after  a  Pirogoff  as  from  one  to 
two  inches ;  that  after  a  Syme  as  two  and  a  half  to  three  inches. 

+  The  continuance  of  this  wasting  is  shown  by  the  hospital  patient  being  for  some 
time  obliged  to  stuff  the  socket  of  his  elephant-boot  with  a  sock.     It  is   not  intended 


692 


OPERATIONS  OX  THE  LOWER  EXTREMITY. 


(Amer.  Journ.  Med.  Sci,  1864,  pp.  121,  129)  has  pointed  out  that,  in  a 
Pirogoif,  the  origin  and   insertion    of  the   gastrocnemius   being   both 


Fig.  288. 


I.  The  incisioDs  in  Pirog(;fi''s  amputation.  The  dotted  line  shows  the  directiou 
of  the  plantar  incision  in  that  of  Synie.  2.  The  incisions  in  sub-astragaloid  ;  and 
3.  Those  in  Chopart's  amputation. 

intact,  the  combined  movements  of  the  knee  and  ankle  are  preserved, 
as  in  running,  &c. 

Fig.  289 

Fig.  290 


Compare  with  Fig.  284. 


Operation. — The  position  of  the  patient's  foot  and  the  surgeon  being 
as  at  p.  688,  an  incision  is  made,  straight  across  the  sole,  from  the  tip 
of  the  external  malleolus  to  a  point  half  an  inch  below  the  internal  one.* 

by  this  to  depreciate  the  value  of  a  Syme's  stump.  Every  surgeon  knows  how  much 
good,  lifelong  work  the  heel-flap  is  capable  of,  however  much  it  shrinks,  so  long  as  it 
has  healed,  *  I.e.,  not  pointing  backwards. 


PIROGOFF'S  .l^IPUTATION. 


693 


This  incision  goes  right  down  to  the  bone.  Its  horns  are  then  joined 
by  a  transverse  cut  across  the  front  of  the  ankle.  The  lateral  ligaments 
are  now  severed,  care  beingf  taken  to  cut  inside  the  malleoli  and  to 
divide  the  posterior  tibial  artery  as   long  as   possible — i.e.,  below  its 

Fig.  291. 


Fig.  292. 


Division  of  the  os  calcis  iu  Pirogofif'-s  amputation. 

origin  into  the  two  plantar — and  not  to  prick  it   after  it  is  divided. 

With  a  few  touches  of  the  knife  at  either  side  of  the  astragalus,  aided 

by  twisting  of  the  foot  from  side  to  side  and  forcible  bending  of  it 

downwards,  the  non-articular  part  of  the  upper  surface  of  the  os  calcis 

comes     into    view    (Fig.    291).       A 

groove  is  now  cut  through  the  fatty 

tissue    and  the  periosteum,  and  the 

saw    applied   just    in    front    of   the 

tendo-Achillis,  vertically  downwards 

(vide  Fig.  291),  care  being  taken  to 

bring  it  out  through  the  incision  in 

the  heel.     The   foot  being  removed, 

the  soft  parts    around   the  bones   of 

the  leg  are  carefully  cleared  to  a  level 

just  above  the  tibial  articular  surface 

and  the  malleoli,  where  the  saw  is 

next  applied,  and  the  bones  divided 

transversely. 

The  vessels,  the  tibials,  anterior 
peronseal,  and  perhaps  one  or  both 
malleolar  having  been  secured,  the  tendons  ciit  square,  the  bony  sur- 
faces are  placed  in  contact,  and,  if  needful,  drilled  with  a  sterilised 
bradawl  and  united  with  wire  or  stout  chromic  gut.* 

*  If  the  patient  is  young  and  healthy,  this  step  is  not  absolutely  needful.  I  would 
recommend  it  in  other  cases.  Thus  I  have  made  use  of  it  in  a  PirogofE's  amputation  for 
inveterate  infantile  paralysis,  with  excellent  results.  If  wire  be  used,  it  must  be  left 
long.     A  little  ether  will  probably  be  needed  when  the  wire  is  removed. 


PirogofE's  amputation  as  modified  by  Dr. 
E.  Watson.    (Smith  and  Walsham.) 


694 


OPERATIONS  OX  THE  LOWER  EXTREMITY. 


If  it  is  found  advisable  to  convert  the  Pii'ogofF  into  a  S^'me,  all  that 
is  needed  is  to  divide  the  tendo-Achillis  and  to  dissect  out  the  part  of  the 
OS  calcis.  keeping  the  knife  close  to  the  bone. 

Modiflcations  of  Pirogoflf  s  Amputation. — One  of  the  chief  of  these 
is  that  introduced  by  Dr.  E.  Watson  {Lancet,  1 859,  vol.  i.  p.  S77)- 
He  claims — (i)  That  it  is  shorter  and  easier,  the  trouble  of  disarticu- 
lation being  avoided.  (2)  That  it  is  less  likely  to  damage  the  posterior 
tibial  artery.  (3)  That  it  does  awaj-  with  one  of  the  chief  difficulties 
in  a  PirogolTs  amputation  for  injury — viz.,  the  want  of  purchase  over 
the  smashed  parts  while  the  os  calcis  is  being  sawn  thi'ough. 

Operation. — The  operator,  standing  as  before,  having  cut  across  the 
sole  from  the  tip  of  one  malleolus  to  the  corresponding  point  (p.  692) 
down  to  the  bone,  introduces  a  small  Butcher's  saw,  or  one  with  a 
narrow  blade,  into  this  wound,  and  saws  off  the  posterior  part  of  the 
OS  calcis  by  carrying  his  section  upwards  and  backwards.  This  and  the 
heel  being  now  retracted  by  an  assistant  (Fig.  292),  the  surgeon, 
resuming  his  knife,  cuts  upwards  behind  the  ankle-joint  between  the 
sawn  bones.  The  ends  of  the  iirst  incision  are  now  joined  by  one 
passing  between  them,  the  skin  being  pulled  up  a  little  and  the 
tendons  and  vessels  severed  cIoaati  to  the  tibia  and  fibula  just  above 
the  ankle-joint.  Lastly,  these  bones  are  sawn  through  in  a  slanting 
manner  by  directing  the  saw  from  before  backwards  and  downwards.* 
AYhile  the  bones  of  the  leg  are  being  sawn,  the  heel-flap  should  be 
held  well  up  against  the  back  of  the  leg  to  keep  it  out  of  the  way. 

Modifications  by  Sedillot,  Gunther,  and  Le  Fort. — It  is  obvious 
that  if  the  bones  are  divided  as  advised  by  Pirogoff — i.e..  the  os  calcis 


Fig.  293. 


Fig.  294. 


Modifications  of  Pirogoff's  ampntatiou  Ly  St'dillot  aud  Gunther.    (Farabeuf . 


vertically  downwards  and  the  tibia  and  fibiila  transversely — the  patient, 
when  the  bones  are  united,  will  come  to  walk,  not  upon  the  thick  fibro- 
fatty  cushion  under  the  tuberosities  of  the  os  calcis,  but  upon  the  thin 
skin  over  the  insertion  of  the  tendo-Achillis.  To  obviate  this  Sedillot 
and  Gunther  have  advised  the  very  oblique  section  of  the  bones  shown 
in  Figs.  293  and  294.     Pasquier  Le  Fort  goes  still  farther  and  saws 

*  It  will  be  noticed  that  the  direction  of  the  bone  section  above  given  by  Mr.  "Watson 
is  contrary  to  that  usually  taught. 


SUB-A STRAGALOID  .UIPUTATIOX. 


695 


through  the  os  calcis,  horizontally,  parallel  to  its  articular  surface,  the 
bones  of  the  leg  being  also  sawn  horizontally.  Sir  W.  Mac  Cormac  thus 
describes  the  chief  steps  of  the  operation,  Siir^j.  Oper.,  pt.  ii.  p.  237. 
The  incision  in  the  soft  parts  is  commenced  three-quarters  of  an  inch 
below  the  external  malleolus  and  continued  forwards  as  far  as  the 
anterior  third  of  the  calcaneum.  Having  reached  this  point  the  knife 
describes  a  curve,  across  the  dorsum  of  the  foot,  whose  anterior  convexity 
corresponds  to  the  astragalo-scaphoid  articulation.  When  the  knife 
reaches  the  inner  border  of  the  foot  it  is  made  to  pass  backwards,  and 
stops  one  inch  in  front  of  and  below  the  inner  malleolus.  A  slightly 
curved  plantar  flap  is  then  made,  which  passes  transversely  across  the 
sole  of  the  foot  and  rejoins  the  first  incision  below  the  external  malleolus. 
The  tibio-tarsal  joint  having  been  next  opened,  the  upper  margin  of  the 
OS  calcis  is  exposed  and  the  saw  made  to  traverse  the  bone  horizontally 
forwards.     The  remaining  connections  are  then  divided. 


SUB-ASTRAGALOID  AMPUTATION  (Figs.  295-297). 

This  operation  consists — the  soft  parts  being  divided  as  at  Fig.  295  or 
296 — in  opening  the  astragalo-scaphoid  joint  from  the  dorsum,  and  the 
astragalo-calcanean  of  which  the 

interosseous  ligament  can  only  be  ^^^-  -95- 

divided  by  introducing  the  knife 
point  from  the  outer  side.  The 
whole  foot  is  then  removed  in  one 
mass  with  the  exception  of  the 
astragalus,  which  is  left  mortised 
in  between  the  tibia  and  fibula. 
When  the  stump  is  healed,  this 
bone  should  rest  upon  the  ground 
by  its  inferior  surface.  If,  \\o\\- 
ever,  the  stump  should  be  pulled 
up  by  the  tendo-Achillis  and  other 
cut  muscles  taking  on  a  firm  at- 
tachment, it  will  be  the  head  of  the 
astragalus  alone  which  will  rest 
upon  the  ground  and  transmit  the 
A\eight  of  the  body.  While  this 
has  the  advantage  of  diminish- 
ing the  shortening  of  the  limb, 
it  has  the  grave  inconvenience  of 
narrowing  the  basis  of  support, 
and  of  bringing  the  weight  of  the  body  upon  that  part  of  the  stump 
where  the  cicatrix  is  necessarily  found. 

This  amputation,  very  rarely  practised  in  England,  has,  with  that  of 
M.  Tripier  (p.  715),  largely  replaced  that  of  Chopart  in  France.  The 
majority  of  English  surgeons  have,  I  believe,  had  reason  to  be  satisfied 
with  Chopart's  amputation,  in  spite  of  the  objections  brought  against  it 
(p.  713).  The  following  account  is  taken  from  Dr.  Stimson,  Man.  of 
Oper.  Surg.,  p.  113:  — 

"The  guides  to  this  operation  are  the  tip  of  the  external  malleolus 


The  incision  in  Malgai^iie's  sub-astragaloid 
amputation.     (Mae  Cormac.) 


696 


OPERATIONS  ON  THE  LOWER  EXTREMITY. 


and  the  head  of  the  astragalus.  The  joint  must  be  entered  from  in 
front  on  the  fibular  side,  and  the  strong  interosseous  ligament  M'hich 
forms  the  key  to  the  articulation  must  be  divided,  step  by  step,  from 
before  backwards  and  inwards.  The  posterior  tibial  vessels  must  be 
carefully  avoided. 

"  Beginning  at  the  outer  side  of  the  heel  nearly  one  inch  below  the 
tip  of  the  external  malleolus,  an  incision  extending  through  to  the  bone 
is  carried  straight  forward  to  the  base  of  the  fifth  metatarsal  bone,  thence 
curving  forwards  across  the  dorsum  of  the  foot  to  the  base  of  the  first 
metatarsal,  thence  obliquely  backwards  and  outwards  across  the  sole  of 
the  foot  and  around  its  outer  border,  rejoining  the  first  horizontal  part 
of  the  incision  at  the  calcaneo-cuboid  joint.  The  soft  parts  must  be 
separated  from  the  outer  surface  of  the  calcaneum  and  cuboid  witii 
division  of  the  perona3al  tendons,  the  dorsal  flap  dissected  back  to  the 
head  of  the  astragalus,  and,  on  the  inner  side,  beyond  the  tubercle  of 


Fig.  296. 


Fig.  297. 


Sub-astragaloid  amputation  (right  foot)  by  large 
internal  and  plantar  flap.     (Farabeuf.) 


Sub-astragaloid  amj)utation 
(left  foot)  by  large  internal 
and  plantar  flap.     (Farabeuf.) 


the  scaphoid,  thus  dividing  the  tendon  of  the  tibialis  anticus  and  the 
anterior  portion  of  the  internal  lateral  ligament.  The  interosseous 
ligament  can  then  be  easil}^  reached  by  depressing  the  toes,  passing  the 
knife  between  the  astragalus  and  scaphoid,  and  cutting  backwards  and 
inwards  along  the  under  surface  of  the  former.  The  soft  parts  on  the 
inner  side  are  then  separated  from  the  calcaneum,  injury  to  the  vessels 
being  avoided  by  keeping  close  to  the  bone  between  it  and  the  tendons 
of  the  flexor  communis,  the  foot  depressed,  and  the  tendo-Achillis 
divided.  This  last  is  a  very  difficult  part  of  the  operation,  and  great 
care  must  be  taken  to  keep  the  edge  of  the  knife  close  to  the  bone  so  as 
not  to  cut  through  the  skin.  The  posterior  tibial  nerve  should  be  dis- 
sected out  and  cut  off"  as  high  as  possible,  so  that  it  shall  not  be  pressed 
upon  in  the  stump." 

M.  Farabeuf  advises  an  internal  and  plantar  flap,  whose  nutrition  is 
guaranteed  by  a  very  large  base.     This  is  the  flap  of  Eoux  (Figs.  285, 


EXCISION  OF  THE  ANKLE.  697 

286),  made  considerably  longer  in  front.  The  incision  passes  parallel 
to  the  outer  border  of  the  foot,  a  full  finger's-breadth  below  the 
external  malleolus,  as  far  as  the  tuberosity  of  the  fifth  metatarsal,  then 
across  to  the  scapho-cuneiform  articulation,  and  the  extensor  proprius 
pollicis  tendon.  Then  it  descends  over  the  middle  of  the  inner  border 
of  the  foot,  as  far  as  the  centre  of  the  sole.  Here  it  begins  to  turn  back 
along  the  outer  border  of  the  foot,  as  far  as  the  posterior  extremity  of 
the  OS  calcis,  where  it  joins  the  starting-point.  Fig.  296  shows  the 
dissection  of  this  flap  in  the  case  of  the  right  foot :  the  left  hand  of  the 
operator  raises  and  protects  the  soft  parts  in  front  of  the  knife,  which  is 
kept  parallel  to  the  vessels  and  tendons  lying  under  the  sustentaculum 
tali.     Fig.  297  shows  the  flap  before  it  is  sutured. 


EXCISION     OF    THE    ANKLE. 

This  operation  is  one  of  very  disputed  value,  and  thus  rai'ely  per- 
formed. Objections:  (i)  Disease  here  is  often  associated  with  disease  of 
the  tarsus.  (2)  Even  if  the  wound  heals,  the  foot  left  is  often  of  little 
use.  (3)  Syme's  amputation  affords  not  onl}"  a  radical  cure,  but  a  most 
excellent  stump.  This  may  be  imperilled  by  a  previous  excision  of  the 
joint. 

Indications. — These,  which  are  ver}'  few,  must  be  considered 
separateh",  according  as  they  fall  under  the  heading  of  :  A.  Disease. 
B.  Injur II . 

A.  Disease. — (i)  The  patient  must  be  young  and  healthy,  with  no 
evidence  of  other  tubercular  disease,  or  of  phthisis  or  syphilis.  (2)  The 
disease  should  be  of  traumatic  origin — e.g.,  following  a  sprain — and  (3) 
limited  to  the  bones  which  form  the  joint,  the  whole  astragalus  being- 
taken  away  if  needful.  To  another  class  of  cases  in  which  this 
operation  has  been  too  often  performed — viz.,  where  the  patient's  health 
is  reduced  by  discharge,  pain,  hospital  air,  &c.,  where  other  tarsal 
bones  are  involved — this  excision  is  not  applicable ;  it  is  here  much 
severer  than  amputation,  and  leaves  the  patient  most  liable  to 
recurrence.*  Quite  a  separate  instance  of  excision  in  disease  may  be 
occasionall}^  practised  in  advanced  cases  of  infantile  paralysis.  Here 
the  ankle  may  be  excised  (by  a  transverse  incision)  some  time  after 
the  knee  has  been  submitted  to  the  same  operation,  in  order  to  give  a 
firm  basis  of  support  in  good  position,  instead  of  a  flail-like  limb 
which  shuts  up  at  the  knee  and  ankle  fp.  638). 

The  chief  points  in  excision  of  the  ankle-joint  which  have  been 
raised  as  objections  to   the    operation   are:   (i)  The    difficulty  of  free 

*  In  Mr.  Holmes's  words  ^Syst.  of  Stirg.,  vol.  iii.  p.  766),  in  the  first  class  of  case 
'•  the  iuflammatory  softening  or  suppuration  does  not  usually  extend  far  from  the 
neighbourhood  of  the  joint  originally  implicated,  and,  after  the  removal  of  the 
■diseased  bone,  the  parts  take  on  a  healthy  action  and  become  rapidly  consolidated, 
In  strumous  disease,  on  the  other  hand,  inflammatory  softening,  if  not  diffused 
suppuration,  often  exists  in  the  tarsal  bones  or  bones  of  the  leg  in  parts  not  exposed 
to  view  in  the  operation ;  and,  in  patients  labouring  under  general  constitutional 
affections,  the  parts  operated  on,  instead  of  consolidating,  usually  soften,  and  after  a 
loDg  and  exhaustive  suppuration  the  bones  are  found  carious,  leaving  no  resource 
except  amputation,  and  that  sometimes  under  unfavourable  circumstances." 


698  OPERATIONS  ON  THE  LOWER  EXTREMITY. 

exposure  of  the  parts  to  be  dealt  with;  (2)  The  frequency  with  which 
other  bones  are  diseased.  Thus  Mr.  F.  Jordan*  strongly  objected  to  the 
operation  on  the  ground  that  the  astragalus  is  not  a  long  bone  with  an 
epiphysis  in  which  the  chief  disease  may  lie,  but  a  short  bone  consisting 
of  a  mass  of  cancellous  tissue  throughout  which  the  disease  is  more  or 
less  diffused.  This  objection  may  be  answered  by  the  fact  that  if  the 
disease  in  the  astragalus  is  found  not  to  be  limited  to  the  upper 
articular  surface,  it  will  in  no  way  interfere  with  the  results  if  the 
whole  bone  is  removed.!  And  this  fact  will  meet  another  objection  to 
excision  of  the  astragalus  made  by  Prof.  Syme — viz.,  that  the  frequency 
with  which  disease  of  the  astragalus  originates  on  the  under  surface  of 
this  bone  (i.e.,  between  it  and  the  os  calcis+)  calls  rather  for  amputation 
than  excision.  (3  j  The  difficulties  of  securing  afterwards  a  splint  which 
will  combine  the  three  following  essentials — viz.,  (a)  Sufficient  rest ; 
(/>)  Sufficient  exposure  for  needful  change  of  dressings  ;  (c)  The  pos- 
sibility of  antiseptic  ti-eatment.  Two  excellent  but  too  little  known 
splints  are  Esmarch's  bracket-splint,  and  the  iron  splint  moulded  to  the 
back  and  front  of  the  leg,  and  front  and  sole  of  foot,  and  covered  with 
india-rubber,  introduced  by  Mr.  Paul  of  Liverpool.  This  is  a  model  of 
combined  usefulness  and  simplicity.  Both  are  secured  in  place  with 
plaster  of  Paris.  But  if,  in  addition  to  much  of  a  cavity  to  fill  up,  any 
tendency  to  oedema  remains,  a  back  and  two  side  splints — all  three 
being  interrupted — are.  in  my  opinion,  preferable. 

B.  Injury. — In  a  young,  healthy  patient,  where  the  vessels  and 
nerves  are  mainl}-  intact,  where  the  mischief  is  limited  to  the  ends  of 
the  bones,  an  attempt  to  save  the  limb  by  excision,  partial  or  complete, 
is  abundantly  justified.  The  steps  given  at  p.  679  for  the  antiseptic 
treatment  of  compound  fractures  should  be  carefully  attended  to,  as  to 
the  preservation  of  periosteum,  the  due  providing  of  drainage,  etc.  As 
to  gunshot  injuries,  Dr.  Otis  (Med.  and  Surg.  Hist,  of  the  War  of  the 
BeheUion,  pt.  iii.  p.  610)  thought  that  "the  substitution  of  excision  of 
the  ankle-joint  for  amputation  effected  no  saving  of  life,"  formal 
excisions  being  rarely  successful. 

Operation. — This  may  be  either  by  two  lateral  incisions,  or  by  a 
transverse  one,  dividing  the  extensor  tendons,  which  are  sutured 
afterwards. 

Excision  by  Lateral  Incisions. — An  Esmarch's  bandage  having  been 
applied  above,  and  the  parts  rendered  evascular  as  well,  the  foot  is  laid 
upon  its  inner  side  firml)'  supported  on  a  sand-bag.  An  incision  is 
made  along  the  lower  two  and  a  half  inches  of  the  posterior  border  of 
the  fibula,  and  then,  when  it  has  reached  the  tip  of  the  malleolus,  it  is- 


*  Lancet,  1897,  ^^l.  i.  p.  729. 

t  Mr.  Holmes,  whose  experience  of  this  operation  is  a  large  one,  advises  QBrit.  3fccL 
Joiirn.,  1878,  vol.  ii.  p.  875)  that  the  whole  of  the  astragalus  should  always  be  removed, 
for  these  reasons— (i)  As  it  is  often  softened  to  a  considerable  depth,  mere  removal 
of  its  articular  surface  will  often  leave  disease  behind;  (2)  in  patients  low  iu  health, 
or  of  strumous  constitution,  the  violence  done  by  the  saw  may  prove  the  starting- 
point  of  renewed  caries ;  (3)  the  bones  of  the  leg  unite  quite  as  firmly  to  the  exposed 
cartilaginous  surfaces  of  the  os  calcis  and  scaphoid  as  they  do  to  the  sawn  surface  of 
the  astragalus ;  (4)  the  shortening  is  not  appreciably  increased ;  (5)  the  difficulty  of 
the  operation  is  lessened. 

X  Instances  of  extensive  removal  of  the  bones  of  the  tarsus  are  given  at  pp.  706,  707, 


EXCISION  OF  THE  ANKLE. 


699 


carried  downwards  and  forwards  at  an  angle  to  within  an  inch  of  the 
base  of  the  fifth  metatarsal  bone.  A  slight  flap  is  now  sufficiently 
dissected  forwards  to  expose  the  bone  and  to  clear  the  perongei ;  these 
being  drawn  aside,  the  bone  is  divided  with  a  narrow  saw  or  cutting- 
forceps  about  two  inches  above  the  malleolus,  and  removed  after 
division  of  the  external  lateral  ligament.  This  wound  is  now  covered 
with  sterile  gauze,  the  foot  turned  over,  and  a  similar  angular  incision 
made  along  the  lower  two  inches  of  the  inner  margin  of  the  tibia, 
and  then  forwards  and  downwards  as  far  as  the  projection  of  the 
internal  cuneiform  bone.*  A  flap  being  dissected  slightly  inwards,  the 
tendons  of  the  tibialis  and  flexors  are  exposed  and  retracted,!  the  knife 
being  kept  close  to  the  bone  so  as  to  avoid  the  posterior  tibial  vessels. 

The  internal  lateral  ligament  is  now  cut  through  close  to  the  tibia, 
and  on  disjDlacing  the  foot  outwards  the  tibia  and  astragalus  present  in 
part  at  the  inner  wound.  A  metacarpal  saw  being  next  passed  from 
the  inner  to  the  outer  wound,  the  lower  end  of  the  tibia  is  sawn  off 

Fig.  29S. 


Mac  Cormae's  splint  for  excision  of  the  ankle.     The  shape  can  be  modified  by  bending 
the  wire,  and  the  limb  immobilised  by  plaster  of  Paris  (Mac  Cormac). 

sufficiently  high  up  to  secure  a  healthy  section  of  bone,  and  no  more. 
The  astragalus  is  next  treated  similarly,:!:  all  the  articular  cartilage  being 
removed.  Any  soft  patches  of  bone  are  next  gouged  out,  and  pulpy 
material  snipped  away  from  the  synovial  sheaths  of  the  tendons,  &c. 
All  sinuses  are  next  scraped  out  or  laid  open.  The  only  vessels  which 
will  require  tying  are  some  branches  of  the  peronseal  and  the  malleolar, 
none  of  any  importance  being  divided.  Very  few,  if  any,  sutures  should 
be  used,  so  as  to  allow  of  very  free  drainage. 


*  The  lower  extremities  of  these  incisions  need  not  go  down  to  the  bones. 

f  Unless  these  tendons  are  sufficiently  freed  from  their  connection  with  the  lower 
end  of  the  tibia,  difficulty  will  be  met  in  everting  the  foot  sufficiently  to  bring  the 
tibia  out  of  the  wound  (Hancock,  Lancet,  1867,  vol.  i.  p.  731). 

X  If  the  disease  here  is  at  all  extensive,  this  bone  should  be  entirely  removed 
(p.  698).  If  a  section  only  of  the  astragalus  is  taken,  much  difficulty  will  be  met  in 
removing  the  upper  articular  surface.  Thus,  unless  the  saw  be  directed  properly,  the 
astragalo-scaphoid  or  astragalo-calcanean  joints  may  be  opened.  To  meet  the 
difficulty  of  fixing  the  foot  the  heel  should  be  held  in  the  left  hand,  and  the  upper 
surface  of  the  astragalus  is  pressed  against  the  cut  end  of  the  tibia,  while  an 
assistant  holds  the  leg  firmly  on,  and  a  little  over,  the  edge  of  the  table  (Porter,  Brit. 
Med.  Journ.,  1878,  vol.  ii.  p.  792). 


700  OPEEATIONS  OX  THE  LOWER  EXTREMITY. 

Excision  by  Transverse  Incision. — The  parts  being  rendered  evas- 
cular,  an  incision  is  made  transversely  across  the  front  of  the  ankle-joint 
from  the  tip  of  one  malleolus  to  the  other.  The  extensor  tendons  being 
divided,  the  anterior  and  lateral  ligaments  severed,  the  end  of  the  tibia 
is  exposed,  a  way  cleared  for  the  saw  just  above  the  malleoli,  and  a  slice 
removed.  The  upper  articular  surface  of  the  astralagus  is  then  treated 
in  the  same  way,  the  peronaei  and  flexor  tendons  being  drawn  aside 
while  the  bones  are  sawn.  Any  dead  bone  is  gouged  away  and  pulpy 
tissue  removed,  as  mentioned  above.  Haemorrhage  having  been  arrested, 
the  divided  tendons  are  sutured  with  carbolised  silk. 

In  either  of  the  above  operations  every  care  must  be  taken  to  preserve 
the  periosteum,  especially  where  this  is  softened  and  loosened. 

A  suitable  splint  is  always  a  difiiculty  in  these  cases.  On  the  whole, 
a  back-splint  and  foot-piece,  and  two  side-splints,  all  being  padded  with 
gauze,  will  be  found  most  suitable  for  the  first  ten  or  fourteen  days ;  the 
side-splints,  being  secured  with  straps  and  buckles,  readily  admit  of 
removal  so  as  to  change  the  dressings.  If  all  the  disease  has  been  taken 
away,  and  due  drainage  provided,  the  dressings  will  need  changing 
verj^  infrequenth".  After  the  first  fortnight,  the  limb  may  be  put  up  in 
one  of  Esmarch's,  Paul's,  or  Mac  Cormac's  splints,  secured  with  plaster 
of  Paris.  Another  arrangement  which  answers  well  with  a  quiet  patient 
is  to  put  up  the  limb  on  its  outer  side,  with  the  knee  flexed,  on  an 
outside  angular  splint  interrupted  opposite  the  wound,  the  splint  being 
duly  supported  with  pillows.  If  the  external  wound  is  left  freely  open, 
this  method  gives  good  drainage. 


ERASION    OF    ANKLE-JOINT. 

Indications. — The  above  operation  should  be  emploj^ed  when  the 
following  conditions  co-exist :  A  young  subject  with  good  power  of 
repair ;  tubercular  disease  limited  to  the  ankle-joint ;  absence  of 
disease  in  other  joints  or  viscera.  Where  these  conditions  do  not  co- 
exist, a  Syme's  amputation  is  in  my  opinion  to  be  unhesitatingly 
preferred,  owing  to  the  excellent  stump  which  it  gives ;  where  disease 
has  been  left  here  too  long,  and  where  the  tibia  is  involved,  and  the 
soft  parts  undermined  and  riddled  with  sinuses,  and  the  tendon 
sheaths  involved  high  up.  an  amputation  of  the  leg  may  be  required. 

Erasion  of  the  ankle-joint  will  obviouslj"  be  of  limited  use,  as  in 
many  cases  several  of  the  tarsal  bones  are  involved  in  addition  to  the 
ankle-joint,  and  when  the  subject  is  not  young,  failure  of  an  erasion 
or  excision  of  the  ankle-joint  imperils  greatly  the  success  of  a  Syme's 
amputation. 

Operation.— As  in  excision  of  the  ankle-joint  the  different  methods 
class  themselves  under  two  heads :  (A)  A  transverse  incision.  (B) 
Lateral  incisions.  (A)  Erasion  by  a  transverse  incision. — G.  A. 
Wright,  of  Manchester,  who  gave  such  a  healthy  impetus  to  erasion 
of  joints,  thus  describes  a  case  operated  on  as  long  ago  as  1882 
{Diseases  of  Children.  Ashby  and  Wright,  p.  633)  : 

The  child  was  8  years  old.  The  joint  was  opened  by  a  transverse  incision  across  the 
front  of  the  joint,  dividing  all  the  extensors,  kc,  much  pulpy  synovitis  existed  with 
subchondral  caries ;  all   the   pulpy    tissue,  as  well  as   the   loosened   cartilage  were 


ERASIOX  OF  AXKLE-JOINT. 


701 


removed  as  far  as  possible.  The  tendons  were  stitched  together  with  catgut  and  the 
wound  closed.  No  attempt  was  made  to  unite  the  nerve,  the  anterior  tibial  artery- 
was  twisted.  The  wound  was  very  slow  in  healing,  but  three  years  later  the  child's 
condition  was  as  follows  :  "  foot  sound  and  well,  but  the  toes  are  somewhat  pointed, 
and  he  '  throws '  the  foot  in  walking.  He  gets  about  well  with  a  boot  and  without 
any  support.  A  good  deal  of  new  bone-formation  about  line  of  incision,  but  some 
mobility." 

Mr.  W.  A.  Lane  has  extended  the  above  method  by  a  transverse 
incision,  as  follows  (Clin.  Soc.  Trans.,  vol.  xxvii.  p.  15):  "An  incision 
is  made  from  the  anterior  margin  of  the  tip  of  the  inner  malleolus 
across  the  front  of  the  ankle,  then  backwards  immediately  below  the 
external  malleolus  around  the  heel  to  within  a  measurable  distance  of 
the  flexor  longus  hallucis,  everything  being  divided  down  to  the  bone. 
The  only  structures  about  the  ankle-joint  which  are  left  uncut  are  the 
internal  lateral  ligament,  the  tendons  of  the  flexor  longus  dicritorum 
and  tibialis  posticus,  the  posterior  tibial  vessels  and  nerve,  and  the 
superjacent  connective-tissue  and  skin.  The  interior  of  the  ankle-joint 
can  then  be  exposed  as  readily  as  one  separates  the  pages  of  a  book,  and 
the  whole  of  its  synovial  membrane  exposed.  The  narrow  prolongation 
of  synovial  membrane  upwards  between  the  tibia  and  fibula  is  shown 
more  completely  by  dividing  the  inferior  interosseous  and  anterior  tibio- 
fibular ligaments."  Some  care  is  required  in  putting  up  the  limb  in 
plaster  after  the  operation,  that  the  fibula  does  not  fall  back  a  little 
from  its  normal  position.  Finding  that  union  of  the  divided  tendons 
is  not  satisfactory,  Mr.  Lane  (Clin.  Soc.  Trans.,  vol.  xxxii.)  now  divides 
the  peronffii  only,  and  at  some  distance  above  the  joint.  The  other 
tendons  are  exposed  for  some  distance  and  drawn  aside. 

(B)  Erasion  by  Lateral  Incisions. — Mr.  Glutton,  believing  that 
such  a  very  free  division  of  the  structures  around  the  ankle-joint  is  not 
necessary  in  erasion,  has  recently  advocated  this  method  (Trans.  Med. 
Chir.  Soc,  vol.  Ixxvii.  p.  loi).  "The  method*  of  procedure  was  by  a 
series  of  vertical  incisions  round  the  ankle-joint,  through  which  a  sharp 
spoon,  and  even  a  finger,  could  be  introduced.  Four  incisions,  one  in 
front  and  another  behind  each  malleolus,  avoiding  ligaments  and 
tendons  by  freely  opening  the  joint,  were  generally  employed.  If 
traction  was  made  on  the  foot  the  finger  could  always  be  introduced  to 
examine  the  joint  surfaces  after  the  use  of  the  sharp  spoon.  The  nozzle 
of  an  irrigator  with  a  full  stream  of  aseptic  fluid  was  kept  constantly 
going  through  one  or  other  of  the  openings  round  the  joint.  The 
introduction  of  the  finger  was  especially  useful  in  hunting  for  soft 
patches  of  tubercular  granulation-tissue,  for  then  the  sharp  spoon  could 
be  introduced  to  that  spot.  In  most  cases  the  cartilage  came  away  and 
the  bone  beneath  was  attacked  with  more  or  less  vigour,  according  to 
the  condition  of  the  fragments  which  were  removed.  An  objection  has 
been  raised  to  this  method  of  procedure,  namely,  that  the  surgeon 
cannot  see  the  condition  of  the  structures  upon  which  he  is  operatino-. 
But  if  the  finger  is  used  as  described  above,  and  when  the  bone  is  being 
scraped,  the  fragments  are  carefully  examined,  there  is  really  little 
difficulty  in  arriving  at  a  conclusion  as  to  when  enough  has  been  done. 
The  consistence  of  the  bone  and  its  resistance  to  the  action  of  a  sharp 

*  As  stated  by  Mr.  Glutton,  an  exactly  similar  method  of  operating  is  described  by 
Eruns  QMiinchener  Med.  Woch.,  1891). 


702  OPEEATIOXS  OX  THE  LOWER  EXTREMITY. 

spoon  is  not  alone  sufficient,  for  in  the  neighbourhood  of  a  diseased 
articulation  the  bone  is  often  rarefied  without  being  invaded  with 
tubercle."  A  copious  dressing  was  applied,  and  over  this  a  plaster-of- 
Paris  splint  was  put  on  with  an  iron  bar  at  the  back,  and  windows  at 
each  side.  When  the  patient  was  able  to  get  up,  a  knee-rest  was 
ordered  to  be  used  for  man}"  months.*  An}-  persistent  sinus  must  be 
scraped  out  without  delaj'  (p.  647). 

Mr.  Glutton  gives  six  cases  which  have  been  treated  by  him  by 
erasion  with  longitudinal  incisions.  As  to  the  results  Mr.  Glutton  is 
certainly  correct  in  claiming  that  they  "are  sufficientl}"  encouraging  to 
make  one  think  that  more  effort  should  be  niade  in  the  conservative 
treatment  of  the  joint  than  appears  at  present  to  be  the  practice  of 
operating  surgeons." 

As  to  which  of  the  two  methods  is  the  best  it  is  clear  that  good 
results  can  be  secured  by  either.  Speaking  for  myself  only,  I  am  of 
opinion  that  in  most  hands  a  transverse  incision,  prolonged  as  freely  as 
needful,  will  give  the  best  exposure  of  the  joint,  and  thus  facilitate  the 
eradication  of  all  the  diseased  tissue  which  is  so  essential  in  dealing  with 
tubercular  joints  (p.  639). 


EXCISION     OF    BONES    AND    JOINTS     OF     THE     TARSUS. 

Before  considering  these  separateh',  I  would  invite  attention  to  the 
following  practical  points : 

i.  Those  cases  are  the  least  hopeful  in  which  there  is  no  history  of 
injury,  in  which  there  is  evidence  of  a  tubercular  constitution,  or 
perhaps  of  disease  dating  to  an  exanthem  and  coupled  with  the  above 
constitution ;  cases  in  which  the  patient  is  wan  and  sickly  with  long 
lasting  pain  and  sleeplessness ;  cases  in  which  the  parts  are  much 
swollen,  dusky  red,  and  glossy.  Avith  sinuses  numerous  or  excavated, 
giving  vent  to  watery,  ill-smelling  discharge — all  points  denoting  a 
disease  that  is  not  limited  to  one  joint  or  to  few  bones,  ii.  Mere  laying 
open,  and,  still  more,  injection,  of  sinuses  where  there  is  disease  of  the 
tarsus  is  absolutely  useless  in  most  cases,  iii.  When  a  patient  is  under 
care  for  caries  of  the  foot,  his  luno;s  should  alwavs  be  cai'efullv  examined 
before  operative  treatment  is  undertaken,  iv.  When  the  amount  of 
disease  present  is  being  estimated,  it  must  be  remembered  that  patients, 
especially  children,  will  often  use  their  feet  with  much  freedom,  limping, 
even  bearing  their  weight  on  their  toes  with  the  aid  of  a  crutch,  though 
all  the  time  extensive  disease  is  present,  v.  That  before  an  operation, 
the  parts  should  always  be  rendered  absolutely  evascular  b}^  the  use  of 
Esmarch's  bandages,t  and  that  thus  the  limit  of  the  disease  should  be 

*  Free  movement  iu  the  medio-tarsal  joint  often  made  up  for  anj-  ankylosis  of  the 
ankle-joint. 

t  This  is  disputed  by  some.  I  strongly  advise  it.  The  free  oozing  after  this  method 
may  be  met  by  tying  any  vessels  which  are  seen  in  the  absolutely  drj'  wound,  and  then 
usually  plugging  this  with  strips  of  iodoform  gauze,  wrung  out  of  carbolic-acid  lotion. 
I  in  20,  bandaging  firmly  over  well-applied  dressings  before  the  Esmarch's  bandage  is 
removed,  and  giving  sufficient  morphia  in  the  first  twelve  hours.  This  dressing  will 
iseldom  require  removal  for  several  days,  when  the  strips  must  be  thoroughly  soaked 
before  removal. 


EXCISION  OF  THE  A8T1JAGALUS. 


703 


Fig. 


deKned  as  accuratel}'  as  possible,  vi.  Sub-periosteal  excision  is  only 
advisable  in  the  case  of  single  bones  where  the  periosteum  is  already 
thickened  and  loosened,  and  that  in  other  cases  it  is  not  of  such  great 
advantage  as  to  justify  any  considerable  prolongation  of  an  operation, 
vii.  Strict  antiseptic  precautions 
should  be  made  use  of  wherever 
this  is  possible,  because — (ci)  Pro- 
longed suppuration  will  exhaust 
a  patient  whose  powers  are  already 
sufficiently  handicapped  by  dis- 
ease and  operation  ;  (h)  Suppura- 
tion will  cause  destruction  of  the 
periosteum,  and  thus  fresh  caries 
and  necrosis  ;  (c)  Interference 
with  inflamed  bones  may,  if  sepsis 
result,  easily  cause  osteo-myelitis 
and  pygemia.  viii.  When  the 
question  arises  between  excision 
and  amputation,  if  the  powers  of 
repair  have  been  duly  considered, 
the  question  of  time  and  the  rank 
of  life  should  also  be  remem- 
bered. Thus,  after  an  extensive 
excision,  six  months  will  pro- 
bably" be  required  before  the  foot 
can  be  used,  but  only  three 
months  after  an  amputation. 
The  time  in  the  first  case  may 
after  all  be  wasted,  a  point  of 
much  importance,  when  the  ques- 
tion of  schooling,  learning  a 
trade,  &c.,  have  to  be  considered. 
ix.  No  use  of  a  foot  can  be  per- 
mitted after  an  operation  till 
firm  consolidation  is  obtained. 
X.  If  pulpy  mischief  persist  after 
an  operation,  the  sharjD  spoon 
must  be  freely  used,  together  with 
laj'ing  open  sinuses,  snipping 
away  of  undermined  skin,  c^c. 
If  all  carious  bone  has  been  re- 
moved, the  above  steps  may  be  repeated  again  and  again  here,  as  in 
the  knee,  with  ultimate  success. 


To  show  the  arrangement  of  the  tarsal  synovial 
membranes.     (Mac  Cormae.) 


EXCISION    OF    THE    ASTRAGALUS. 


Indications. — These  will  be  for  A.  BiseaKC,  B.  Injimj. 

A.  Disease. — (i)  Caries  of  the  bone,  especially  when  comparatively 


*  A  good  instance  of  the  occasional  value  of  this  operation  has  been  given  by  my 
old  friend  George  A.  Wright  (^Peudlchury  Abstracts,  18S4,  p.  124).     The  case  was  one  of 


704  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

recent  and  of  traumatic  origin  in  a  young  and  healthy  patient,  and 
when  the  disease  is  found  to  be  limited  to  the  upper  surface.  (2)  In 
disease  of  the  astragalo-calcanean  joint,  where  it  is  thought,  from  the 
position  of  the  sinuses,  &c.,  to  be  more  advisable  to  expose  this  joint  by 
removing  the  astragalus  than  the  os  calcis.  (3)  Talipes  :  in  inveterate 
resistant  cases  (p.  711). 

B.  Injuri/. — (i)  Primarily,  (a)  In  simple  dislocation  of  the  astragalus 
not  reducible  with  the  aid  of  aneesthetics  and  tenotomj^  of  the  tendo- 
Achillis  and  the  tibials  or  extensors,  if  it  seem  certain  that  the  skin  will 
slough.  (//)  In  compound  dislocation  of  the  astragalus  when  the  bone 
is  too  far  displaced  or  comminuted  to  admit  of  replacement,  and  when 
the  condition  of  the  soft  parts,  vessels,  and  tendons  does  not  call  for 
amputation.  (2)  Secondarily,  when  the  foot  is  useless  and  painful. 
In  these  cases,  especially,  strict  antiseptic  precautions  must  be  taken 
and  free  drainage  provided. 

Operation. — This  may  be  performed  by  two  lateral  or  a  transverse 
incision,  with  subsecjuent  suture  of  the  tendons.  On  account  of  the 
freer  exposure  given.  I  prefer  the  latter.  The  parts  having  been 
rendered  evascular,  the  bone  is  exposed  by  an  incision  crossing  the 
dorsum  between  the  malleoli,  as  in  Syme's  amputation ;  the  tendons 
are  cleanly  cut,  and  the  astragalus  exposed.  At  this  stage  all  that  may 
be  required  is  to  remove  a  sequestrum  from  the  upper  surface  of  the 
neck  of  the  bone.  The  ligaments  must  be  divided  by  carefully  keeping 
the  knife  close  to  the  bone  *  while  this  is  twisted  out  in  the  grasp  of 
lion-forceps,  aided,  if  needed,  by  the  levering  movements  of  an  elevator, 
care  being  taken,  in  using  this,  not  to  bruise  any  soft  bone  which  is 
used  as  a  fulcrum.  If  the  astragalo-calcanean  joint  is  found  diseased, 
this  must  be  now  attended  to  with  chisel,  gouge,  and  sharp  spoon. 
The  scaphoid  is  next  examined.  All  pulpy  material  having  been 
removed,  htemorrhage  is  arrested,  the  tendons  carefully  sutured,  and 
the  wound  closed,  drainage  being  provided  if  necessary-. 


EXCISION   OF  THE   OS   CALCIS. 

Practical  Remarks. — Disease  here  is  not  very  infrecpient,  and  often 
remains  limited  to  this  bone  for  a  long  time.  It  may  commence  in  one 
of  three  sites — viz.,  (a)  the  posterior  epiphysis,  which,  not  appearing 
until  the  tenth  year,  does  not  unite  till  between  the  fifteenth  and  nine- 
teenth years ;  (h)  the  body  of  the  bone ;  (c)  the  calcaneo-astragaloid 
joint,  either  de  novo,  or  as  an  extension  of  the  last.  The  diagnosis  of 
primary  disease  in  this  joint  is  often  difficult ;  thus  the  swelling  and 


severe  talipes  valgus,  due  to  infantile  paralysis  of  a  year's  standing.  The  reaction  of 
the  muscles  to  faradism  was  extremely  poor.  "  The  deformity  clearly  depended  on  a 
partial  sub-astragaloid  dislocation."  The  bone  was  removed  by  aa  incision  along  the 
inner  border  of  the  tibialis  anticus,  and  a  shorter  one  meeting  this  between  the 
tibialis  anticus  and  posticus.  No  tendons  were  cut ;  one  small  vessel  required 
twisting.  The  foot  could  be  inverted  into  good  position  after  removal  of  the  bone. 
Twelve  months  later  the  child-  could  walk  painlessly  and  much  more  freely,  without 
eversion,  and  with  a  good  arch. 

*  Especially  at  the  back  and  on  the  inner  side. 


EXCISION   OF  THE   OS  CALCIS. 


705 


position  of  the  sinuses  recall  disease  of  the  ankle-joint.  The  pain  is 
usually  greater  than  in  ordinary  disease  of  the  os  calcis  itself,  and  the 
foot  is  sooner  disabled.  With  an  anaesthetic,  the  ankle-joint  is  found 
free,  and  probes  introduced  by  sinuses  may  pass  towards  the  level  of 
the  upper  surface  of  the  os  calcis  (known  by  the  tubercle  for  the 
extensor  brevis). 

Operation. — The  parts  being  rendered  evascular  and  the  foot  firmly 
supported  on  its  inner  side  at  the  edge  of  the  table,  an  incision*  is 
made  with  a  strong-backed  scalpel,  commencing  at  the  inner  edge  of 
the  tendo-Achillis,  and  passing  along  the  upper  loorder  of  the  os  calcis 
(vide  supra)  at  the  outer  border  of  the  foot  as  far  as  the  calcaneo-cuboid 
joint,  which  lies  midway  between  the  outer  malleolus  and  the  fifth 
metatarsal  hone.  This  incision  should  go  down  at  once  upon  the  bone, 
so  that  the  tendon  should  be  felt  to  snap  as  the  incision  is  commenced. 


Fk;.  300 


Foot  two  years  after  removal  of  os  calcis  iu  a  child.  The  foot  is  flat 
but  very  serviceable.  As  will  be  seeu  from  the  state  of  the  calf,  the  teudo- 
Achillis  has  taken  on  a  fresh  attachment  iu  the  detached  periosteum,  and 
has  been  well  employed. 

Another  incision  is  then  to  be  drawn  verticall}'  across  the  sole,  com- 
mencing near  the  anterior  end  of  the  first,  and  terminating  just  short 
of  the  inner  surface  of  the  os  calcis,  beyond  which  it  should  not  extend 
for  fear  of  wounding  the  posterior  tibial  vessels.  The  bone  being  no^\■ 
exposed  by  throwing  back  the  flap,  the  calcaneo-cuboid  joint  is   first 


*  The  above  incision  is  taken  from  Mr.  Holmes'  article  ((S^pf.  of  Surg.,  vol.  iii. 
p.  771).  A  still  better  one  is  that  advised  by  Farabeuf  {Man.  Oper,,  p.  759)  : — A 
horseshoe-shaped  incision  is  made  round  the  heel,  beginning  at  the  calcaneo-cuboid 
joint,  dividing  the  tendo-Achillis,  and  ending  on  the  inner  aspect  of  the  foot, 
external  to  the  posterior  tibial  vessels  and  nerves.  To  this  incision  a  short  vertical 
one  is  added,  running  up  along  the  outer  side  of  the  tendo-Achillis.  By  turning  aside 
the  flaps  thus  marked  out  the  bone  is  most  thoroughly  exposed. 

VOL.   II.  45 


yoG  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

found  and  opened.  The  perontiei  must  be  dissected  out,*  and  drawn 
aside  with  a  bhmt  hook.  The  astragalo-calcanean  joint  is  next 
attacked ;  and  the  close  connection  between  the  bones  at  this  point 
constitutes  the  principal  difficulty  of  the  operation,  unless  the  ligaments 
have  been  destroj'ed  by  disease.  This  difficulty  can  best  be  met  by 
grasping  the  bone  firmly  with  lion-forceps,  and  wrenching  it  backwards 
and  outwards,  aided  b}"  levering  movements  of  an  elevator,  and  a  knife- 
point kept  very  close  to  the  bone.  Especial  care  must  be  taken  on  the 
inner  side  to  avoid  the  vessels.  The  bone  being  removed,  the  gap  is 
lightly  plugged  with  gauze,  and  the  dressings  applied  before  the 
Esmarch's  bandage  is  removed. 

The  question  of  preserving  the  periosteum  has  already  been  referred 
to,  p.  703.  Some  good  cases  of  excisions  of  tarsal  bones  are  recorded 
by  Mr.  Holmes,  Sijd.  of  Surg.,  vol.  iii.  p.  769  et  seq. ;  and  Surg.  Treat, 
of  Childreris  Bis.,  chap.  xxvi. 


OPERATIOlSrS    FOR    MORE     COMPLETE    TARSECTOMY. 

It  is  scarceh*  worth  while  to  give  directions  for  the  removal  of  other 
single  bones — e.g.,  the  scaphoid  and  cuboid — as  these  are  rarely 
diseased  alone,  and,  if  this  should  be  so,  their  removal  is  easy. 

The  operations  of  Mickulicz  and  of  Dr.  P.  H.  AYatson  will  be 
described  to  meet  those  cases  where  more  extensive  disease  is  present, 
and  where  the  patient's  age  and  condition  justify  a  trial  of  these  severe 
operations  instead  of  amputation.  In  the  very  few  cases  which  call  for 
these  operations  AYatson's  is  to  be  preferred,  as  it  leaves  a  foot  at  right 
angles  with  the  leg. 

Operation  of  Mickulicz.-f- — The  object  of  this  operation  is  to  procure 
an  artificial  pes  equinus,  and  to  preserve  the  toes  and  metatarsals,  these 
being  brought  into  a  straight  line  with  the  leg,  and  the  toes  bent  at  a 
right  angle,  so  that  the  patient  walks  on  the  ends  of  the  metatarsal  bones 
covered  by  the  thick  pads  of  tissue  which  invest  them  ;  a  broader  surface 
of  support  is  provided  than  after  Syme's  or  Pirogoff's  amputations,  and 
there  is  some  elasticity  of  the  foot  left.  I  do  not  recommend  this 
operation,  and  only  introduce  the  account  from  my  respect  for  the 
sm-geon  whose  name  it  bears.  The  result  is  obtained  at  far  greater 
cost  and  risk  than  that  by  a  Sonne's  amputation,  and  is,  in  my  opinion, 
of  very  doubtful  siiperiorit}'.  Mr.  Bland  Sutton  (Lancet,  1893,  vol.  ii. 
p.  1 5 1 3)  brought  before  the  Aledical  Society  the  skeleton  of  a  foot  three 
years  after  the  performance  of  Mickulicz"s  operation.  The  artificial  pes 
equinus  had  been  produced  by  Sir  AY.  Mac  Cormac  in  a  girl,  aged  18, 
the  subject  of  infantile  paralysis.  In  spite  of  the  anatomical  success  of 
the  operation  the  foot  was  of  little  service  in  progression,  causing  the 
girl  much  pain  and  inconvenience,  and  Mr.  Sutton  removed  the  leg  by 
amputating  through  the  knee-joint. 

*  Mr.  Holmes  (jioc.  svpra  cit.')  says  that  he  has  always  divided  these  without  ill 
effect.  Care  must  be  taken  in  drawing  them  aside,  for.  if  this  is  done  too  vigorously, 
one  may  slough,  as  happened  to  me  in  one  of  my  cases. 

t  The  account  of  this  is  taken  from  a  paper  of  SirW.  Mac  Cormac's  (^Lancet,  May  5, 
1888),  four  figures  accompanying  this.  Mickulicz's  paper  will  be  found  in  Langenbeck's 
Arch.,  1881,  Bd.  xxvi.  S.  191. 


TAHSECTOMY.  707 

Sir  W.  Mac  Cormac's  i:)atieiit  was  aged  15,  and  the  disease  dated  to  a 
sprain  of  the  ankle.  On  the  lad's  admission  the  swelling  and  sinuses 
pointed  to  disease  of  the  os  calcis ;  later  on  the  ankle-joint  became 
involved.  Amputation  being  refused,  Sir  W.  Mac  Cormac  operated 
thus:  "The  patient  was  placed  in  the  prone  position.  If  it  be  the 
right  foot,  the  knife  is  introduced  on  the  inner  border  of  the  foot,  just 
in  front  of  the  scaphoid  tubercle,  and  a  transverse  incision,  extending  to 
the  bone,  is  made  across  the  sole  to  a  point  a  little  behind  the  tuberosity 
of  the  fifth  metatarsal.  On  the  left  foot  the  direction  of  this  incision 
will  be  reversed.  From  the  inner  and  outer  extremities  of  the  wound 
incisions  are  prolonged  upwards  and  backwards  over  the  corresponding 
malleolus,  and  their  extremities  united  by  a  transverse  cut  across  the 
back  of  the  leg,  do^\'n  to  the  bone,  at  the  level  at  which  it  is  to  be 
sawn,  usually  immediately  above  the  joint  surface  of  the  tibia.  In 
cases  where  a  larger  removal  of  the  tibia  and  fibula  is  required,  the 
lateral  incisions  must  be  more  oblique,  and  the  posterior  transverse  cut 
made  at  a  higher  level.  The  ankle-joint  is  now  opened  from  behind, 
the  disarticulation  completed,  and,  after  flexing  the  foot,  the  soft  parts 
are  carefully  separated  in  front  until  the  medio-tarsal  joint  is  reached, 
through  which  disarticulation  is  effected  as  in  Chopart's  amputation. 
The  heel  portion  of  the  foot,  consisting  of  the  astragalus,  calcis,  and  the 
soft  parts  covering  them,  is  thus  removed.  The  articular  surfaces  of 
the  tibia  and  fibula,  with  the  malleoli,  are  now  sawn  off,  as  Avell  as 
those  of  the  cuboid  and  scaphoid.  The  anterior  portion  of  the  foot 
remains  connected  with  a  bridge  of  soft  parts.  The  blood-suppl}"  appears 
to  be  ample,  for  almost  directly  after  the  operation  blood  issued  freely 
from  the  distal  ends  of  the  divided  plantar  arteries.  All  heemorrhage 
having  been  arrested,  the  foot  was  brought  into  a  straight  line  with  the 
leg,  and  the  cut  surfaces  of  the  bone  were  sutured  together  with 
kangaroo  tendon.  The  attempt  to  discover  and  unite  the  divided  ends 
of  the  posterior  tibial  nerve  failed,  on  account  of  the  sodden  condition 
of  the  soft  parts.  Suitable  dressings  and  a  plaster-of-Paris  splint  were 
applied,  the  toes  being  brought  into  a  position  of  complete  dorsal 
flexion." 

The  boy  made  an  excellent  recovery.  Firm  bony  union  took  place. 
In  about  a  month  sensibility  began  to  return  in  the  sole,  and  gradually 
became  more  complete.     The  toes  were  mobile.* 

Operation  of  Watson. — This  is  adapted  to  cases  ^here  the  medio- 
tarsal  articulation  is  involved,  the  importance  of  which,  from  the 
number  of  bones  and  the  complicated  synovial  membrane,  is  well 
known  (p.  717).  In  other  words,  the  disease  should  be  situated 
between  the  bases  of  the  metatarsal  bones  in  front  and  the  os  calcis  and 
the  astragalus  behind.  The  parts  being  rendered  evascular,  incisions 
three  to  four  inches  long  are  made,  on  the  outer  side  from  the  centre  of 
the  os  calcis  to  the  middle  of  the  fifth  metatarsal  bone,  and  on  the  inner 
from  the  neck  of  the  astragalus  to  the  middle  of  the  first  metatarsal. 
The  soft  parts  are  carefully  dissected  ofi"  from  the  dorsal  and  plantar 


*  The  patient  was  shown  to  the  Medical  Society  more  than  a  year  after  the  opera- 
tion. "  He  walked  up  and  down  the  room,  both  with  and  without  his  boot,  with  great 
ease  and  evident  satisfaction  to  himself.  The  union  is  quite  solid,  and  he  now 
attends  to  his  daily  work  without  any  inconvenience." 


708  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

aspects  of  the  foot  b}^  means  of  these  incisions,  the  left  thumb  being 
kept  between  the  point  of  the  knife  and  the  soft  parts.  With  a  curved 
probe-pointed  bistoury  the  joints  between  the  astragakis  and  scaphoid, 
and  03  calcis  and  cuboid,  are  opened  up,  and,  a  saw  being  passed 
between  the  plantar  soft  parts  and  the  metatarsal  bones,  these  are  cut 
through  from  below  upwards.  The  diseased  bones  being  removed,  the 
wound  is  firmly  plugged  and  pressure  applied  with  gauze  pads  and 
bandages  before  the  tourniquet  is  removed.  That  this  operation,  though 
little  known,  is  an  excellent  one  in  Dr.  Watson's  hands,  is  shown  by  the 
fact  that  five  out  of  his  six  cases  did  well.  It  must  be  remembered 
that  it  is  an  operation  in  the  dark,  and  one  that  may  involve  a  good 
deal  of  damage  to  soft  parts,  owing  to  the  amount  of  disease  which  has 
to  be  removed  bv  somewhat  limited  incisions. 


REMOVAL     OF    TARSAL    BONES    FOR    INVETERATE 

TALIPES. 

Indications. — Cases  which  deserve  the  above  epithet  of  inveterate, 
in  which  tenotomy,  sjnidesmotomy,  and  forcible  manipulation*  have 
been  thoi'oughly  tried  ;  cases  in  which  there  is  evidently  confirmed 
alteration  in  the  shape  of  the  bones — e.r/.,  in  talipes  equino-varus — such 
rigidity  that  the  position  of  the  foot  cannot  be  jDOssibly  altered,  the 
astragalus  projecting  outwards  on  the  dorsum,  and  the  scaphoid  so 
displaced  that  it  almost  touches  the  internal  malleolus ;  where  the 
patient  walks  on  the  outer  border  of  his  foot,  and  large  bursse  have 
formed  over  the  cuboid  ;  and  where  the  patient  is  prevented  from  earn- 
ing his  livelihood.  Finally,  the  surgeon  must  feel  assured  as  to  his 
power  of  conducting  the  case  aseptically. 

The   chief   operations    for    inveterate    or   resistant    talipes    are — 

(i)  Complete  section  either  by  open  incision,  Phelps'  opera- 
tion, or  by  subcutaneous  section  ;  (ii)  Removal  of  the  astra- 
galus ;  (iii)  Cuneiform  tarsectomy.  Before  they  are  described 
1  would  impress  most  strongly  upon  ni}^  younger  readers  the  cardinal 
importance  of  the  following :  (i)  Kelapses  will  follow  after  any  opera- 
tion, however  complete  and  severe  at  the  time,  unless  the  patient  is  kept 
under  observation  sufficiently  long  for  the  surgeon  to  feel  certain  that 
the  case  is  cured.  (2)  Relapses  depend  either  upon  the  patient  being  too 
soon  removed  from  supervision,  or  upon  the  surgeon  saying  prematurelj" 
that  the  cure  is  complete.  (3)  No  cure  is  complete  until  the  patient 
has  been  walking,  under  skilled  observation  at  intervals,  for  a  sufiicient 
time.  It  is  quite  impossible  to  lay  down  any  law  or  limit  here.  For 
cases  before   puberty    several    years    are    required  ;    for  adolescents  or 


*  Either  by  the  hands  or  by  the  aid  of  Thomas's  wrench.  An  excellent  account  of 
the  use  of  this — in  fact,  one  of  the  very  best  descriptions  of  the  treatment  of  talipes 
in  the  English  language — is  given  by  Mr.  K.  Jones,  of  Liverpool,  and  Dr.  Ridlon,  of 
Chicago,  in  the  Medical  Annual  for  1896,  p.  448.  Another  very  helpful  account  of 
talipes  is  that  given  by  Mr.  Tubby  in  his  recently  published  work  on  Orthopaedic 
Surgery. 


REMOVAL  OF  TARSAL  BOXES  FOR  TALIPES.  709 

adults  at  least  one  year  is  needed.  The  more  severe  the  case  the  more 
care  is  required  for  the  surgeon  to  be  absolutely  certain  that,  when 
walking-  is  allowed,  the  body-weight  falls  on  the  foot  in  the  riglit 
position,  and  not  unduly  on  the  outer  side,  perpetuating,  if  even  in  the 
slightest  degree,  the  varus.  (4)  While  there  is  no  routine  method  of 
operation  in  these  cases,  the  surgeon  will,  of  course,  secure  the  best 
results  from  that  operation  with  which  he  is  most  familiar. 

Phelps'  Operation  by  Open  Incision.* — The  foot  having  been 
cleansed  and  rendered  evascular  is  placed  on  its  outer  side,  and  a  line  is 
drawn  from  the  tip  of  the  inner  malleolus  to  the  tuberosity  of  the 
scaphoid.  From  the  centre  of  this  line  an  incision  is  made  outwards 
across  the  inner  third  of  the  sole,!  down  to  the  neck  of  the  astragalus  on 
its  inner  side.  Through  this  wound  the  plantar  fascia,  abductor 
hallucis,  tibiales  posticus  and  anticus,  the  long  flexors,  together  with 
the  internal  lateral  and  calcaneo-scaphoid  ligaments,  are  divided.  If 
possible,  the  internal  plantar  vessels  and  nerve  are  spared.  Great  force 
is  then  used  to  rupture  the  deeper  ligaments  and  over-correct  foot. 
Phelps  also  divides  the  tendo-Achillis  at  the  same  time;  others  prefer  to 
leave  this  step  till  a  later  occasion.  The  wound,  partly  sutured,  is  put  up 
without  drainage,  and  must  heal  partly  under  bloodclot,  partly  by 
granulation.  The  foot  is  maintained  in  the  over-corrected  position  by 
plaster  of  Paris. 

This  operation  has  been  modified  in  various  ways  in  order  to  avoid 
the  tendency  to  recurrence  which  results  from  the  contraction  of  the 
scar  left  on  the  inner  side  of  the  foot. 

Mr.  W.  A.  Lane  (Lancet,  Aug.  19,  1893)  piits  on  a  large  skin  graft 
on  the  second  day,  in  order  to  promote  more  rapid  healing.  Mr.  T.  H. 
Kellock  (Lancet,  March  30,  1895)  partially  fills  the  gap  by  means  of  a 
skin  flap  from  the  dorsum  of  the  foot.  Dr.  W.  Gardner,  of  Melbourne, 
quoted  by  Tubby  (Orthopcedic  Surg.,  p.  435),  inserts  a  wedge  of  decal- 
cified bone  between  the  scaphoid  and  astragalus,  "  to  which  bones  it  is 
wired,  and  by  this  the  lengthening  of  the  inner  side  is  maintained  until 
the  plate  is  replaced  by  fibrous  tissue." 

Finally,  the  following  excellent  modification  is  described  by  Dr.  A.  F. 
Jonas  (Ann.  of  Surg.,  April  1899,  p.  449),  and  has  been  employed  by 
him  in  twenty-five  cases,  with  satisfactory  results.  Here  a  V-shaped 
flap  is  turned  back  while  the  structures  beneath  are  divided  ;  the 
flap  is  then  replaced,  the  wound  being  sutured  in  the  form  of  a  Y. 

The  operation  is  described  as  follows :  "An  incision  is  made  begin- 
ning slightly  belo^v  the  margin  of  the  plantar  fascia  on  the  inner  side  of 
the  foot,  at  a  point  on  a  line  directly  below  and  anterior  to  the  internal 
malleolus,  extending  forwards  and  upwards  to  a  point  on  the  first 
metatarsal  bone,  and  nearly  to  the  metatarso-phalangeal  articulation.  A 
second  incision  is  made  beginning  at  a  point  over  the  astragalo- 
scaphoid  articulation,  extending  forwards  and  slightly  downwards, 
joining  the  first  incision  near  the  metatarso-phalangeal  joint,  forming  a 
V.     The  incisions   are   made   deep   so  as  to   include  the  subcutaneous 


*  Mr.  E.  Owen  strongly  advocates  this  operation  in  an  excellent  account  of  it  (J/t-<-/.- 
Chir.  Trans.,  vol.  Ixxvi.  p.  Sg). 

t  Phelps  originally  made  his  incision  two-thirds  across  the  sole,  but  modified  it 
owing  to  the  tender  scar  which  was  liable  to  result. 


7IO  OPERATIONS   OX   THE  LOWER   EXTREMITY. 

tissue  and  fat.  The  flap  is  dissected  backward  to  the  points  first 
indicated.  "We  have  now  exposed  all  the  shortened  soft  structures. 
We  first  sever  diagonally  the  inner  fascictilus  of  the  plantar  fascia. 
The  diagonal  division  of  the  plantar  fascia  is  done  so  that  after  correc- 
tion the'i-e  shall  not  be  left  a  defect  between  the  divided  ends,  but  that 
the  points  of  the  incised  fascia  still  come  in  contact,  thereby  lessening 
the  tendenc}-  to  contraction  of  this  structure  when  repair  is  complete. 
The  remaining  structures  are  now  divided  successively  as  directed  by 
Phelps,  until  the  astragalo-scaphoid  capsule  is  reached.  Instead  of 
dividing  this,  we  make  another  incision  on  the  outer  side  of  the  foot, 
over  the  head  of  the  astragalus,  pushing  aside  the  tendons  and  soft 
structures  and  exposing  the  neck  of  that  bone,  and  then  cut  through 
the  neck  with  a  chisel.  We  can  now  push  the  forward  part  of  the  foot 
outward  without  separating  the  astragalo-scaphoid  articulation  which 
neai'ly  always  occurs  in  the  typical  Phelps"  operation."  After  bleeding 
has  been  arrested  the  wounds  are  closed  and  the  limb  put  up  in  plaster 
of  Paris. 

Lane's''  Complete  Subcutaneous  Section. — Mr.  W.  A.  Lane, 
believing  that  the  later  results  of  Phelps'  operation  are  very  unsatisfac- 
tory owing  to  the  "  absolute  loss  of  continuity  of  all  the  soft  parts  in 
the  sole  of  the  foot,"  advises  the  following  method  (Lancet,  vol.  ii.  1893, 
p.  432) :  "An  india-rubber  bandage  is  applied  above  the  knee  to  control 
the  circulation,  so  as  to  prevent  the  free  bleeding  that  would  otherwise 
occur,  and  then,  by  means  of  a  strong,  long-bladed,  sharp-pointed 
tenotomy-knife,  everything  beneath  the  skin  that  opposes  the  placing  of 
the  foot  in  a  position  of  moderate  abduction  upon  the  astragalus  is 
divided.  This  includes  the  several  divisions  of  the  plantar  fascia,  part 
of  the  internal  lateral  and  annular  ligaments,  the  superior  internal 
calcaneo-scaphoid,  the  inferior  calcaneo-scaphoid  and  the  long  and  short 
plantar  ligaments,  together  Avith  the  tibialis  anticus  and  all  the  tendons, 
vessels,  and  nerves  in  the  sole  of  the  foot.  This  cannot  be  done  satisfac- 
torily through  a  single  puncture ;  but  I  do  not  hesitate  to  make  any 
number  of  punctures,  only  taking  care  that  the  knife  is  entered  in  such 
a  direction  that  the  forcible  fixation  of  the  foot  in  a  position  of  abduction 
does  not  cause  the  wound  made  by  it  to  gape.  This  is  a  matter  of 
considerable  importance,  since  it  is  frec[uently  necessary  to  sew  up  the 
apertures  which  are  made  by  the  knife,  otherwise  arterial  blood  spurts 
through  them  on  removing  the  tourniquet.  By  spending  some  time, 
and  by  exercising  a  moderate  amount  of  skill,  it  is  possible  to  divide  all 
the  soft  pai'ts  opposing  abduction  of  the  foot  on  the  astragalus  and  to 
leave  the  skin  intact,  except  for  the  punctures  produced  by  the  tenotomy- 
knife.  After  this  has  been  done,  I  pass  a  knife  between  the  skin  and 
tendo-Achillis  and  divide  it.  If  the  foot  does  not  become  square  I  cut 
all  the  soft  parts  except  the  peronfei,  carefully  dividing  the  posterior 
ligament  of  the  ankle-joint,  which  often  opposes  free  movement  of  this 
articulation." 

With  regard  to  the  above  operations,  I  am  of  opinion  that  cases 
severe  enough  to  require  them  are  best  met  by  cuneiform  tarsectomy 
{vide  infra). 

*  A  somewliat  similar  operation  is  given  bv  Buchanan  (^Brit.  Med.  Jonrn.,  Oct.  27 


RE.MOVAL  OF  TARSAL  BOXES  FOR  TALIPES.  711 

Removal  of  Astragalus  (Lund,  Brit.  Med.  Journ.,  Oct.  19,  1872). 

A  longitudinal  incision*  about  two  inches  long  and  gently  cun-ed,  is 
made  over  the  most  projecting  part  of  the  head  of  the  astragalus  from 
the  external  malleolus  downwards  and  inwards,  between  the  outermost 
tendon  of  the  extensor  longus  digitorum  and  the  peron^eus  tertius.  The 
soft  parts  on  either  side  of  the  incision  having  been  raised  with  an 
elevator,  the  ankle  and  astragalo-scaphoid  joints  are  opened,  the  bone 
is  loosened  in  its  bed  with  an  elevator  while  its  ligamentous  attachments 
are  divided  with  blunt-pointed  scissors.  This  is  facilitated  bv  drawincr 
the  bone  in  different  directions  with  lion-forceps.  The  chief  difficulties 
met  with  are :  (i)  the  closeness  with  which  the  bone  occupies  its  socket, 
and  the  consequent  readiness  with  wliich,  if  a  sharp  instrument  be  used 
to  lever  out  the  astragalus,  slices  of  cartilage  are  detached  from  the 
scaphoid  or  malleoli ;  (2)  division  of  the  ligaments,  especially  the  inter- 
osseous and  the  internal  lateral. 

Advantages.— This  operation  gives  an  excellent  result  in  those  cases 
in  which  the  chief  cause  of  deformity  is  the  astragalus.  A  good  arch 
and  much  mobility  at  the  ankle  are  often  preserved, 

Disadvantages. — In  those  cases  in  which  removal  of  the  astragalus  is 
not  sufficient  to  allow  of  the  foot  being  placed  at  least  at  a  right  angle 
with  the  leg,  the  external  malleolus  must  be  partially  divided  with  bone- 
forceps,  and  then  the  foot  canned  outwards,  bending  the  malleolus 
backwards  and  outwards  also  (Walsham).t  If  this  does  not  suffice  a 
wedge  must  be  removed  from  the  tarsus.  As  I  have  not  found  it  easy 
to  make  sure  in  which  of  these  advanced  cases  removal  of  the  astragalus 
will  suffice,  I  generally  prefer  to  remove  a  wedge  at  once,  as  involving 
less  disturbance  of  the  parts  than  two  operations,  and  as  being  certain. 
Mr.  Walsham,  however,  prefers  beginning  with  removal  of  the  astragalus. 
Mr.  Ewens  (loc.  infra  cif.)  recommends  tarsectomy. 

Cuneiform  Tarsectomy. — This  operation  is  especially  indicated  in 
those  inveterate  or  resistant  cases  of  talipes  where  great  prominence  of 
the  astragalus  is  not  the  prominent  feature,  where  the  fixity  is  too  great 
to  be  overcome  by  the  removal  of  one  bone,  or  where  this  step  has  been 
used  and  failed.  Personally,  I  prefer  this  operation  in  every  case  which 
is  beyond  the  remedy  of  judiciously  employed  "  \\Tenching."  When  I 
say  in  every  case,  I  should  like  to  make  one  reservation.  I  am  referring 
to  the  bulk  of  cases  which  come  before  a  hospital  surgeon.  Where  these 
can  afford  time  and  expense,  where  the  parents  have  the  good  sense  to 
be  patient  over  the  time  which  is  required  to  secure  good  results — in 
such  cases  milder  methods  will  often  suffice.  But  with  the  great  majority 
of  hospital  cases  it  is  not  so.  Time  for  schooling,  apprenticing,  and  so 
forth,  is  urgently  needed,  perhaps  much  has  been  already  lost.  Even 
moderately  expensive  apparatus  is  difficult  of  attainment ;  intelligence 
and  patience  on  the  part  of  the  parents  or  patient  are,  very  often,  not 


*  G.  A.  Wright  (^Diseases  of  Children,  with  Dr.  Ashby,  p.  6S7)  advises  an  incision 
over  the  ankle-joint,  from  the  tibialis  posticus  to  the  anticus,  and  another  incision  at 
right  angles  to  the  first  along  the  inner  side  of  the  tibialis  auticus. 

t  "  When  once  a  bone-operation  has  been  embarked  on,  it  is  no  use  stopping  short 
till  sufficient  bone  has  been  cleared  away  to  permit  of  the  rectification  of  the  foot, 
Xo  more  should,  of  course,  be  removed  than  is  necessarj-,  but  to  take  away  too  little  is 
to  my  mind  mitch  the  graver  fault  "  (Jhid.^. 


712  OPEEATIONS  ON  THE  LOWER  EXTREMITY. 

forthcoming ;  the  regular  attendance  which  is  absolutely  needful  is 
broken  off  or  interrupted,  thus  causing  the  inevitable  relapses  so  well 
known  to  every  surgeon  of  experience.  Looking  upon  treatment  here 
as  mainly  a  question  of  time,  not  only  to  fit  the  patient*  to  play  his  part 
in  life's  battle,  but  because  the  longer  the  deformity  is  left  the  worse 
is  the  habit  of  walking  acquired,  I  generally  resort  to  tarsectomy  in 
patients  as  yoiing  as  ten  or  eleven,  and  very  occasionally  even  younger. 
I  admit  the  foot  is  flat  and  shortened,  and  in  some  cases  stiff,  though 
this  last  is  due  to  imperfect  after-treatment  and  insufficient  manipulation 
and  active  and  passive  exercise  of  the  foot.  Though  Jiat  and  shortened, 
the  foot  is  square,  without  any  tendency  to  inversion,  after  a  ivellr-managed 
tarsectomy.  This,  I  maintain,  is  the  chief  object  before  us  in  these 
resistant  cases  of  talipes,  and,  as  it  is  attained  most  speedily  and  cer- 
tainly by  tarsectomy,  I  recommend  this  operation  strongl}^  in  poorer 
patients  who  can  least  afford  to  lose  time. 

With  regard  to  the  matter  of  age,  I  would  refer  my  readers  to  papers 
by  Mr.  Walsham  (Brit.  Med...  Journ.,  1893,  vol.  i.  p.  339)  and  Mr.  Ewens, 
Surgeon  to  the  Bristol  Children's  Hospital  (ibid.,  1891,  vol.  ii.  p.  843). 
Both  these  surgeons  advocate  resort  to  removal  of  bone  at  an  earlier  age 
than  is  usually  allowed ;  both  consider  such  operative  steps  justifiable, 
in  special  cases,  in  children  only  three  years  old.  In  Mr.  Walsham's 
words  :  "I  have  not  done  a  bone  operation  on  these  patients  at  a  younger 
age  than  two  or  three  years,  but  at  that  tender  age  I  have  found  that, 
even  after  removal  of  the  astragalus,  the  foot  in  some  instances  could 
not  be  got  into  a  satisfactory  position  until  further  portions  of  the  bones 
had  been  excised."  Where,  with  the  advantages  of  a  well-ordered  special 
department,  skilled  assistants  and  nurses,  and  ample  experience,  Mr. 
Walsham  finds  milder  methods  fail,  other  surgeons — working,  perhaps, 
under  less  happy  surroundings — need  not  fear  to  resort,  in  like  occa- 
sional cases,  to  removal  of  bone. 

Operation. — The  parts  having  been  rendered  evascular  with  Esmarch's 
bandages,  are  duly  cleansed  and  supported  on  a  sand-bag.  A  T-shaped 
incision  is  then  made  with  the  horizontal  limb  along  the  outer  side  of 
the  foot  over  the  os  calcis  and  the  cuboid,  and  the  longitudinal  one  at  a 
right  angle  to  this  passing  across  the  dorsum  and  ending  over  the 
scaphoid.  The  flaps  thus  marked  out  are  turned  aside.  With  a  periosteal 
elevator  the  tendons  and  vessels  in  the  dorsum  are  now  raised  so  that 
sufficient  room  is  given  for  the  saw  to  pass  between  them  and  the  bones. 
With  a  retractor  on  the  outer  side  the  peronsei  tendons  are  held  out  of 
the  Ava}^,  due  care  being  taken  of  their  sheaths  to  avoid  the  risk  of 
sloughing.  With  a  narrow-bladed  saw,  a  wedge  of  bone  of  sufficient 
size  is  then  removed  by  two  cuts,  one  above  and  one  below,  meeting  at 
the  scaphoid.  The  upper  of  these  will  pass  through  the  os  calcis  to  the 
scaphoid,  the  lower  through  the  cuboid,  thi'ough  the  joint  between  this 
and  the  fifth  metatarsal,  or  through  the  base  of  this  bone,  according  to 
the  severity  of  the  case.  AVhile  these  sections  are  made,  a  blunt  dis- 
sector may  be  pushed  under  the  bones  very  close  to  their  plantar 
surfaces,  so  as  to  protect  the  soft  parts  beneath.  The  wedge  of  bone  is 
then  removed  with  a  lion-forceps,  or  by  levering  it  out  with  an  elevator, 
care  being  taken  not  to  damage  anj  parts  XTsed  as  a  fulcrum.  As  it  is 
twisted  out,  a  few  attachments  to  the  structures  in  the  sole  may  require 
division  or  peeling  off.     If  the  position  of  the  foot  cannot  be  rectified. 


CHOPART'S  A3IPUTAT10X. 


713 


the  gap  must  be  widened  by  removing-  more  bone  either  with  a  saw  or 
with  a  chisel  and  mallet ;  it  is  especially  towards  the  apex  that  this  must 
be  done.*  When  the  foot  can  be  brought  into  good  position  any  tendons 
that  have  been  divided  are  united  with  carbolised  silk  or  chromic  out.  Any 
vessels  which  can  be  seen  are  then  secured,  a  drainage-tube  is  inserted, 
and  the  ^^■ound  partly  closed  ^^■ith  sutures.  Sufficient  gauze  dressings 
are  then  firmly  bandaged  on  before  the  Esmarch's  bandage  is  removed. 
The  foot  is  put  up  with  a  back  and  two  side  splints,  or  on  an  external 
splint  with  an  interruption,  the  knee  being  flexed  and  the  limb  resting 
on  its  outer  side.  Mr.  Davy  has  devised  a  special  splint  to  secure  ever- 
sion.  Morphia  should  be  given  freely  at  first  if  required.  In  six  or 
eight  weeks  the  union  should  be  firm. 

If  after  the  operation  the  foot  still  turns  in  because  the  whole  limb 
does  so,  osteotomy  of  the  femur  at  about  the  junction  of  the  middle  and 
lower  thirds  should  be  performed,  and  the  leg  and  lower  fragment  tunied 
somewhat  outwards. 

Great  care  must  be  taken  during  the  after-treatment  to  keep  the  parts 
aseptic.  Mr.  Da\y  lost  one  case,  two  weeks  after  the  operation,  from 
septicaemia  (Brit.  Med.  Journ.,  1879.  ^'^^-  i-  P-  221).  (Edema,  &c.,  are  of 
very  likely  occurrence,  if,  owing  to  an  insufficient  wedge  being  removed, 
much  force  has  to  be  employed  to  correct  the  inversion.  Occasionally 
complete  closure  of  the  wound  is  delayed  by  the  coming  away  of  a  scale 
of  bone  :  the  ill-vitalised  corns  and  bursal  tissues  may  show  some  signs 
of  sloughing.f 

CHOPART'S    AMPUTATION"    (Figs.   301-304). 

In  this  medio-tarsal  amputation  only  the  astragalus  and  the  os  calcis 
are  retained,  disarticulation  being  effected  through  the  joints  between 
the  above  bones  and  the  scaphoid  and  the  cuboid. 

Value  of  the  Operation. — This  has  been  a  good  deal  disputed.  The 
following  objections  have  been  raised  to  it : 

I .  That  the  tendo-Achillis,  no  longer  counterbalanced  by  the  extensor 
muscles,  which  have  now  lost  their  attachment,  draws  up  the  heel,  tilting 
down  the  scar,  which  now  becomes  tender  and  irritable  (Fig.  304).  2.  In 
the  normal  foot  the  weight  of  the  body  is  transmitted  through  the  astra- 
galus to  the  other  bones  of  the  tarsus  and  metatarsus.  When,  as  in 
this  amputation,  these  bones  have  been  removed,  the  weight  of  the  body 
tends  to  thrust  forward  the  astragalus,  no  longer  supported  by  the  elastic 
bones  in  front,  against  the  scar  (Fig.  304),  and  thus  renders  this  tender 
and  crippling.  The  above  objections  apply  to  the  operation  performed 
for  injury  or  disease,  the  next  to  amputation  for  the  latter  only.  3.  It 
the  operation  be  made  use  of  in  caries,  this  disease  is  likely  to  recur  in 
the  two  bones  left.  In  answer  to  the  first  two  of  the  above  objections 
it  may  be  said  that  this  tendency  to  tilting  upwards  of  the  heel  and 
downwards   of  the  scar  may  be  'met :    {a)    By  stitching  the  anterior 

*  Some  contracted  tendons  may  now  require  division  before  the  inversion  can  be 
completely  overcome.     The  tendo-Achillis  may  be  divided  now,  or  later. 

t  In  a  case  of  Sir.  "\V.  Bennett's  («»«.  Soc.  Trans.,  vol.  xv.  p.  So)  erysipelas  attacked 
the  sinus,  which  was  all  that  remained  of  the  wound,  and  all  the  union  between  the 
bones,  which  had  become  firm,  gave  way.     The  case  ultimately  did  well. 


714 


OPERATIONS  OX  THE  LOWER  EXTREMITY. 


tendons — gjj.,  tibialis  anticus,  extensor  proprius  pollicis,  and  some  of 
the  tendons  of  the  extensor  communis — into  the  tissues  of  the  sole-flap 
with  stout  carbolised  silk  or  chromic  gnt,  so  as  to  give  them  a  fixed  point 
by  which  they  may  counterbalance  the  tendo-Achillis  ;  •'■  (Jj)  by  cutting 
the  plantar  flap  sufiicientlj^  long,  and  securing  firm  primary  union ; 
(c)  by  division  of  the  tendo-Achillis.  This,  however,  is  only  of  fugitive 
value  ;   {(I)  wearing  a  wedge-shaped  pad  in  the  boot ;  (e)  preserving  the 


Fig.  301 


Incisions  in  Chopart's  amputation.     (Fergusson.)  f 

scaphoid,  when  sound,  so  as  to  retain  the  attachment  of  the  tibialis  posticus. 

"  It  has  not  been  shown  that  this  modification  is  of  special  value"  (Treves). 
The  third  objection  is  answered  by  only  performing  this  operation  for 

caries  when  the  disease  is  limited  to  the  front  of  the  foot,  is  of  distinctly 

traumatic  origin,  and  occurs  in  a  healthy  patient. 

Operation  (Figs,  301  and  302). — AnEsmarch's  bandage  being  applied, 

and  the  foot  supported  at  a  right  angle  over  the  edge  of  the  table,  the 

surgeon,  standing  to  the  right  side  of  the  foot,  and  so  that  he  can  easily 

face  the  sole,  places  {e.g.,  on  the  right  side)  his  left  index  and  thumb 

immediately  above  the  tubercle  of 
the  scaphoid  and  the  corresponding 
point  on  the  outer  side — viz.,  the 
calcaneo- cuboid  joint,  which  lies 
midway  between  the  external  mal- 
leolus and  the  base  of  the  fifth 
metatarsal  bone.  He  then  joins 
these  points  by  a  slightl}^  curved 
incision    crossing    the    tarsus,    and 


Fig.  302. 


'<^^555i;       Mull 


dividing    everything    down    to    the 
bones.     The  foot  being  flexed  up- 
wards, a  plantar  flap  is  then  marked 
out  by  an  incision  running  from  the  outer  extremity  of  the  first  up  the 
outer  side  of  the  little  toe,  then  across  the  sole,  and  then  down  the  inner 
side  of  the  great  toe  to  join  the  inner  extremity  of  the  first.+     The  flap 

*  We  owe  this  ingenious  precaution  to  Mr.  Dclegarde,  of  Exeter.  Till  it  is  more 
frequently  made  use  of,  and  a  larger  number  of  cases  are  collected,  the  value  of  this 
amputation  must  remain  somewhat  undecided.  I  have  operated  on  five  occasions — 
one  a  severe  crush,  another  for  the  results  of  perforating  ulcer,  and  in  three  for  caries 
of  the  front  of  the  foot ;  in  all  this  precaution  was  taken,  and  the  stumps  proved  sound 
and  useful.     One  I  have  watched  for  four  years. 

t  Too  much  dorsal  flap  is  shown  here ;  the  next  figure  shows  the  correct  amount. 

%  The  flap  should  be  a  full  inch  shorter  than  that  in  Lisfranc's  operation  (p.  718), 
if  the  tissues  are  sound.  An  unduly  long  and  large  plantar  flap  will  here,  as  after  a 
Lisfranc's  amputation,  form  an  unwieldy  pocket  (Treves). 


TIUPIER'8  AMPUTATION. 


715 


thiis  marked  out  is  raised  with  the  same  precautions  given  at  p.  718. 
It  is  then  held  out  of  the  way,  and  the  anterior  half  of  the  foot  being 
strongly  depressed,  disarticulation  is  effected  by  passing  the  knife 
above  the  tubercle  of  the  scaphoid  between  this  bone  and  the  astra- 
galus, and  then  between  the  concavo-convex  surfaces  of  tlie  calcaneo- 
cuboid joint.  In  effecting  this  the  position  of  the  joints  and  the  shape 
of  the  astragalus  must  be  remembered,  and  Mr.  Skey's  words  borne  in 
mind:  "The  joints  should  be  opened  with  tact  and  not  b}'  force:  if 
the  knife  be  ajDplied  to  the  right  surface,  it  will  pass  without  effort  into 
the  articulation  ;  if  in  the  wrong  direction,  no  force  will  effect  it." 

The  anterior  tibial  and  plantar  arteries  are  then  secured,  and,  on 


Fig.  303. 


Fig.  304. 


Stump  after  Chopart'b  amputatiou. 
(Fergusson.) 


Stump  often  met  with  after  Clio- 
part's  amputatiou,  showing  its  shape, 
the  position  of  the  bones,  and  the  in- 
fluence of  thetendo-Achillis.   (Farabeuf.) 


removal  of  the  Esmarch's  bandage,  any  other  vessels  which  require  it. 
The  flap  is  then  folded  up  over  the  laones,  but  without  any  forcible 
bending,  which  might  interfere  with  the  blood-supply.  While  it  is 
held  in  this  position,  before  anj^  sutures  are  inserted,  the  extensor 
tendons  (vide  supra)  should  be  carefuU}-  stitched  with  sufficienth-  stout 
silk  into  the  fibrous  tissues  which  abound  in  the  plantar  flap,  care  being- 
taken,  in  so  doing,  not  to  puncture  the  external  plantar  vessels,  but  at 
the  same  time  to  secure  a  sufficient  hold.  The  sutures  inserted  to  hold 
the  plantar  flap  in  situ  must  be  sufficient  in  number  and  stoutness,  and 
must  be  retained  till  the  flap  is  soundl}'  healed. 


TRIPIER'S    AMPUTATION*  (Fig.    305). 

This  operation  was  proposed  by  Dr.  L.  Tripiei',  of  Lyons,  as  an 
improved  modification  of  Chopart's  amputation,  over  which  it  is  thought 
to  possess  the  following  advantages  :  ( i )  The  horizontal  division  of  the 
OS  calcis  on  a  level  with  the  sustentaculum  tali  gives  a  large  surface  of 


*  A  case  of  this  amputation  by  Mr.  Hayes,  of  Dublin,  will  he  found  in  the  Brit. 
Med,  Jonrn.,  1881,  vol.  i.  p.  303. 


yi6 


OPERATIONS  OF  THE  LOWER  EXTREMITY. 


support  entirely  free  from  the  objections  to  that  in  Chopart's  amputa- 
tion (p.  713).  Mr.  WagstafFe  {Lond.  Med,  Becord,  1880,  p.  135)  points 
ont  further  advantages — e.g.,  that  less  plantar  flap  is  needed,  and  that 
the  operator  can  see  the  state  of  the  os  calcis,  amputating  higher  if  this 
bone  be  too  much  diseased.  The  advantages  of  M.  Tripier's  amputation 
over  the  sub-astragaloid  (p.  695)  are  :  (i.)  The  limb  is  longer,  (ii.)  the 
section  of  the  os  calcis  gives  a  larger  and  more  solid  basis  of  support. 
(2)  By  making  the  section  of  the  os  calcis,  the  tendons,  especially  the 
tendo-Achillis,  are  better  preserved. 

Plantar  and  dorsal  flaps  are  marked  out  by  the  following  elliptical 
lines,  the  dorsal  starting  from  the  outer  part  of  the  tendo-Achillis  at 
its  insertion,  then  passing  about  an  inch  and  a  quarter  below  the 
external  malleolus  forwards  to  a  point  about  the  same  distance  above 
the  tuberosity  of  the  fifth  metatarsal  bone ;  the  incision  then  curves 
inwards  to  end  at  the  inner  side  of  the  extensor  proprius  hallucis, 
over  the  tarsal  end  of  the  first  metatarsal  bone.  From  this  point 
the  plantar  flap  is  marked  out  by  an  incision  downward  and  forward 

Fig.  305. 


Tripier's  amj)utatioii.     a,  Section  through  the  skin,     b,  Through  the  soft  parts. 

(Bryant.) 

over  the  inner  part  of  the  sole,  about  an  inch  in  front  of  the  base 
of  the  first  metatarsal  bone,  and  then  obliquel}^  across  the  bases  of 
the  metatarsals,  and,  lastly,  backwards,  so  as  to  join  the  dorsal 
incision  over  the  outer  part  of  the  os  calcis.  All  the  dorsal  tendons 
are  then  divided  along  the  line  of  the  incision,  and  the  structures 
in  the  plantar  incision  are  cut  down  to  the  bones.  A  thick  plantar 
flap  is  now  raised  until  the  under  surface  of  the  os  calcis  is  exposed, 
and  the  point  of  the  heel  turned.  Disarticulation,  as  for  Chopart's 
amputation,  is  then  performed.  The  periosteum  covering  the  under 
aspect  of  the  os  calcis  is  now  incised  antero-posteriorly,  and  detached 
from  the  bone  up  to  the  level  of  the  sustentaculum  tali.  The  os  calcis 
is  next  sawn  through  horizontally  from  within  outwards,  on  a  level 
A\ith  the  same  process.  The  projecting  angles  are  then  rounded  ofi", 
and  the  plantar  and  dorsalis  pedis  arteries  tied.  As  in  all  amputa- 
tions, the  nerve  that  will  be  in  the  flap  that  will  bear  pressure — here 
the  posterior  tibial — should  be  trimmed  short. 


AMPUTATION  TIlllOUGlI  THE  METATARSAL  JOINTS. 


717 


AMPUTATION 


THROUGH    THE    TARSO-METATARSAL 
JOINTS    (Figs.  3o6-309> 


This,  though  usually  spoken  of  as  Hej^'s  or  LisfVanc'.s  amputa- 
tion,   includes,    accurately    speaking,    the    following    operations : 

1.  Lisfranc's. — Amputation  by  disarticulation  through  all  the  joints. 

2.  Hey's. — This  is  usually  described  as  amputation  here  by  sawing 
through  the  bases  of  the  metatarsals.  In  reality,  Hey  seems  to  have 
disarticulated  through  the  outer  four  joints,  and  sawn  off  the  project- 
ing internal  cuneiform  (^Observations  in  Surgeri/,   third  edition,  p.  552). 

3.  Skey's.— Disarticulation  through  the  outer  three  and  the  hrst  joints, 
the  second  metatarsal  being  sawn  through  (Oper.  Surr/.,  p.  406). 

Indications. — Few.  (i)  Limited  crushes  in  which  the  sole  is  sound. 
(2)  Disease  limited  to  the  front  of  the  foot.  (3)  Inveterate  bunion, 
with  persistent  sinuses  and  recurrent  attacks  of  cellulitis.  (4)  Perhaps 
perforating  ulcer.     (5)  Some  cases  of  frost-bite, 

0\\^ng  to  the  complexity  of  the  synovial  membrane  here  (Fig.  299), 
any  disease  which  has  invaded  the 
synovial  membrane  between  the  se- 
cond and  third  metatarsals  and  the 
second  and  third  cuneiforms,  has 
also  spread  to  that  between  the  sca- 
phoid and  three  cuneiforms.  This, 
though  of  small  moment  in  cases 
of  injury,  should  put  this  amputa- 
tion aside  in  most  cases  of  disease. 

Lisfranc's  Amputation  (Figs. 
306  and  307). — The  preliminaries 
are  the  same  as  in  Chopart's  ampu- 
tation. The  surgeon,  standing  to 
the  right  side  of  either  foot,  and  so 
as  easily  to  face  the  sole,  places  his 
left  index  and  thumb  on  the  bases 
of  the  little  and  great  toe  meta- 
tarsals respectively.  The  first  of 
these  can  always  be  found  by 
pressure,  even  if  swelling  is  pre- 
sent; if  there  be  any  difficulty 
with  the  latter,  it  will  be  found  a 
full  inch  in  front  of  the  readily 
detected  tubercle  of  the  scaphoid. 
These  two  points  thus  marked  out 
are  joined  by  a  slightly  curved 
dorsal  incision  with  its  convexitj- 
forwards.  As  a  rule,  if  the  tissues 
in  the  sole  are  sound,  no  dorsal 
flap  should  be  made,  the  above 
incision  being  kept  close  to  the 
disarticulation  is  to  be  performed. 

The  foot  being  now  flexed  upwards,  the  surgeon,  looking  towards 
the  sole,  marks  out  a  plantar  flap  by  an  incision  running  from  the 


Lisfranc's  aiaputatiou.     (Mac  Cormac.) 
line    of    the  joints   through  which 


7l8  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

outer  extremity  of  the  first  cut  (for  the  right  foot)  up  the  outer  side 
of  the  foot,  then  across  the  heads  of  the  metatarsals,  and  down  the 
inner  side,  so  as  to  join  the  inner  extremity  of  the  dorsal  incision. 
This  flap  should  be  made  a  little  longer  on  the  inner  than  on  the 
outer  side  of  the  foot,  so  as  to  cover  the  additionally  projecting  bones 
on  this  side.  Its  cut  edge  being  taken  firmly  between  the  finger  and 
thumb,  the  flap  is  then  dissected  up  as  thickly  as  possible — i.e.,  con- 
taining all  the  tissues  possible  in  the  sole.  In  keeping  the  knife 
close  to  the  bones  some  of  the  metatarso-phalangeal  joints  will  pro- 
bably be  opened.  BeloAv  these  the  flap,  if  steadily  pulled  upon,  will, 
with  light  touches  of  the  knife,  readily  separate  from  the  metatarsal 
bones.  The  flap  should  be  raised  evenly,  and  without  scoring  or  any 
button-holes.  The  prominent  bases  of  the  first  and  fifth  metatarsals 
being  laid  bare,  a  few  strong  touches  of  the  point  of  the  knife  may  be 


Fig.  307 


Disarticulation  of  the  second  metatarsal  in  Lisfranc's  amputation.     The  knife  is  being 
used,  as  described  below,  to  separate  the  second  from  the  first  metatarsal  bone. 

required  to  separate  part  of  the  tibialis  anticus  and  peroneeus  longus 
from  the  base  of  the  former.  The  anterior  part  of  the  foot  is  now 
strongly  depressed  so  as  to  stretch  the  dorsal  ligaments,  and  the  knife, 
having  been  thoroughly  carried  round  the  base  of  the  fifth  metatarsal, 
is  drawn  obliquely  forwards  and  inwards  so  as  to  open  the  joints  of  the 
outer  three  metatarsals  with  the  cuboid  and  the  external  cuneiform. 
The  joint  between  the  first  metatarsal  and  the  internal  cuneiform  is 
next  opened,  and,  lastly,  the  second  metatarsal  is  freed  as  follows : 
The  knife  being  held  firmly  in  the  fist,  its  point  is  inserted  between 
the  first  two  metatarsal  bones,  and  the  knife  carried  backwards 
and  forwards  in  an  antero-posterior  direction  in  the  long  axis  of  the 
foot  (Fig.  307).  The  same  is  then  done  between  the  second  and 
third  metatarsals,  and,  the  lateral  ligaments  being  thus  divided,  the 
joint  between  the  second  metatarsal  and  the  middle  cuneiform  is 
found  and  opened,*  this  being  facilitated   by  strongly  depressing  the 

*  The  position  of  this  joint  must  be  remembered,  and  the  way  in  which  the  base  of 
the  second  metatarsal  bone  is  locked  in  between  its  fellows  and  the  cuneiform  bones. 
Its  base  projects  upwards  between  a  third  and  a  quarter  of  an  inch  above  the  others 


A:\rpuTATiox  THROUGH  THE  mp:tataksal  joixt^^ 


719 


foot,  care  being  taken  not  to  do  tliis  so  violently  as  to  separate  the 
second  metatarsal  from  its  upper  epiphysis,  or  to  fracture  the  bone.* 
A  few  remaining  touches  of  the  knife,  aided  by  a  twisting  movement, 
will  then  suffice  to  separate  the  foot. 

The  method  by  disarticulation  ma}'  be  a  useful  test  of  a  candidate's 
knowledge  and  skill  at  an  examination.  In  practice,  sawing  through 
the  metatarsals  just  below  their  bases  may  nearh'  always  be  substituted. 


Fig.  308. 


Fig.  309. 


c,  Internal  cuneiform,  i,  First  meta- 
tarsal. II,  Second  metatarsal.  e, 
Internal  tarso-metatarsal  interosseous 
ligament,  passing  between  internal 
cuneiform  and  adjacent  angle  of  second 
metatarsal,  p,  Peronaeus  longus. 
(Farabeuf.) 


Stump  after  Lisfranc's  amputation. 
(Fergusson.) 


as  giving  equally  good  results  with  a  great  saving  of  time  and  trouble. 
The  truth  of  this  I  have  personally  tested. 

This  method  of  cutting  the  plantar  flap  before  any  attempt  is  made  to 
flisarticulate  is  strongly  recommended  in  preference  to  disarticulating 
immediately  after  making  the  dorsal  incision  by  passing  the  knife 
behind  the  bones  and  cutting  the  flap  from  within  outwards.  In  thus 
disarticulating  before  making  the  plantai-  flap,  it  is  quite  possible  to 
puncture  the  tissues  in  the  sole,  and  perhaps  to  wound  the  external 
plantar  artery.  Again,  passing  the  knife  behind  the  metatarsal  bones 
often  leads  to  a  hitch,  esiDCcially  with  the  projecting  fifth. 

The  dorsalis  pedis  and  the  external  plantar  artery  are  now  secured 
with  any  smaller  vessels  which  need  it.  Tendons  are  cut  square, 
drainage  provided,  and  the  plantar  flap  then  brought  up  and  secured  in 
accurate  position. 

Owing  to  the  thickness  of  the  plantar  flap  and  its  tendency  at  first 
to  unfold  itself  downwards,  numerous  points  of  suture,  of  sufficiently 
stout  wire  or  silk-worm  gut,  must  be  made  use  of. 


*  While  the  surgeon  is  disarticulating  the  metatarsal  bones  the  plantar  tlap  must  be 
held  -well  out  of  the  way  to  prevent  its  being  punctured. 


720  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

AMPUTATION     OF    THE    TOES. 

Practical  Points. — (i)  Any  plantar  scar  is  to  be  avoided.  (2)  The 
line  of  the  metatarso-phalangeal  joints  lies  a  full  inch  farther  back  than 
the  inter-digital  folds  of  the  skin  (Holden).  According  to  Erichsen,  it 
will  be  found,  as  a  general  rule,  that  these  articulations  are  about  the 
same  distance  above  the  web  as  the  points  of  the  toes  are  below  it. 
This,  I  think,  places  the  line  of  the  joints  too  high.  (3)  Partial  ampu- 
tations (save  in  the  case  of  the  great  toe)  are  very  seldom  advisable,  the 
stumps  left  being  of  little  use,  and  inconvenient  owing  to  their  liability 
to  stick  upwards. 

AMPUTATION    THROUGH    THE    PHALANGES    OR    THE 
INTERPHALANGEAL    JOINTS. 

These  operations  are  not  recommended,  for  the  reasons  just  given. 
If  a  patient  insist  on  having  one  performed,  the  directions  already  given 
for  the  lingers  (p.  2,  Vol.  I.)  will  be  found  sufficient. 

AMPUTATION  OF  ANY  OF  THE  FOUR  SMALLER  TOES 
AT  THE  METATARSO-PHALANGEAL  JOINTS. 

This  amputation  is  performed  much  as  in  the  case  of  the  fingers 
(p.  6,  Vol.  I.),  but  the  following  points  must  be  remembered: 

(i)  The  line  of  the  joint  lies  a  full  inch  above  the  web  (vide  supra). 
(2)  The  head  of  the  metatarsal  bone  is  not  here  removed,  so  as  to  leave 
the  supporting  power  of  the  foot  undiminished.  (3)  It  is  most  impor- 
tant to  avoid,  as  far  as  possible,  an}"  scar  on  the  sole. 

The  scar,  a  simple  antero-posterior  one,  is  well  protected  by  the 
adjacent  toes.  The  incision  should  always  be  begun  on  the  dorsum, 
even  in  the  case  of  the  little  toe,  so  as  to  avoid  friction  of  the  boots. 

AMPUTATION    OF    GREAT   TOE    AT    THE    INTER- 
PHALANGEAL    JOINT. 

This  is  usually  performed  with  a  plantar  flap,  much  as  at  p.  10,  Vol.  I. 

AMPUTATION     OF     GREAT    TOE    AT     THE     METATARSO- 
PHALANGEAL   JOINT    (Fig.    310). 

This  is  performed  b}"  the  oval  method  described  at  p.  6,  Vol.  I.     The 

following    points     must    be 
Fig.  310.  borne  in  mind  : 

(i)  Owing  to  the  large 
size  of  the  head  of  the  meta- 
tarsal bone,  the  flaps  are 
often  cut  of  insufficient 
length.  The  incision  must 
be  begun  an  inch  and  a 
quarter  above  the  joint,  and 
carried  well  on  to  the  pha- 
lanx,   one     flap    being     cut 

Dorsal  and  iuternal  flaps  for  amputation  of  the  great    longer     than      the      other     it 
toe  and  the  head  of  its  metatarsal.     (Farabeuf.)  needful.        (2)   The    sesamoid 


AMPUTATION  OF  THE  TOES. 


721 


bones  must  be  left  in  connection  with  the  head  of  the  metatarsal 
bone,  as  any  attempt  to  dissect  them  out  is  likely  to  imperil  the 
vascularity  of  the  flaps,  especially  after  middle  life. 

In  all  other  details  the  steps  of  this  amputation  are  very  similar  to 
those  already  given  at  p.  6,  Vol.  I. 


Fig.  311. 


Fig 


Amputation  of  the  little  toe  by  a  single  dorsal  and  external  flap.     (Farabeuf.) 

Though  it  is  recommended  by  some  excellent  surgeons  to  remove  the 
head  of  the  metatarsal  bone  either  transversely  or  obliqueh'  from  within 
outwards,  this  step,  narrowing  as  it  does  the  treading  width  of  the  foot. 


Fig.  313. 


Fig.  314. 


Amputation  of  great  toe  and  its  metatarsal 
bone  by  internal  flaps.     (Fergusson.) 


The  foot  left  by  the  operation. 
(Fergusson.) 


is  not  advisable,  unless  the  condition  of  the  skin  is  such  as  to  render  it 
impossible  to  obtain  sufficient  flaps  to  cover  the  entire  head. 

AMPUTATION  OF   THE   GREAT    TOE,   TOGETHER  WITH 
REMOVAL  OF  ITS  METATARSAL  BONE.     (Figs.  313  and  314.) 

This  may  be  performed  by  a  modification  of  the   oval    method   as 
described  for  the  fingers  at  p.  9,  Vol.  I. 


VOL.  II. 


46 


CHAPTER    VIII. 
OSTEOTOMY. 

OSTEOTOMY  OF  THE  FEMUR  FOR  ANKYLOSIS  OF  HIP- 
JOINT— FOR  GENU  VALGUM.— OSTEOTOMY  OP  THE 
TIBIA. 

FOR  ANKYLOSIS   OF  HIP-JOINT. 

This  includes  Adams'  operation  of  division  of  the  neck  of  the  femur 
and  Gant's  operation  of  division  of  the  shaft  of  the  femur  just  below 
the  trochanters.  The  latter  being  much  the  simpler,  and  giving 
excellent  results,  will,  I  think,  replace  the  former. 

Indications. — Cases  in  which  the  hip-joint  is  permanently  flexed  and 
stift',  and  the  patient  accordingly  crippled,  either  from  old  hip  disease, 
or  from  ankylosis  after  rheumatic  fever,  pya3mia,  &c. ;  cases  in  which 
extension  has  failed,  together  with  trials  of  straightening  the  limb  with 
the  aid  of  anaesthetics. 

Adams'  operation  divides  the  neck  of  the  femur  subcutaneously 
within  the  capsule.  It  is  best  suited  for  those  cases  in  which  the  neck 
remains  unabsorbed,  as  in  ankylosis  after  rheumatic  fever,  and,  much 
more  rarely,  pyaemia.  A  long  tenotome  or  a  straight  narrow  bistourj^ 
is  entered  a  little  above  the  great  trochanter,  and  carried  straight  down 
to  the  neck  of  the  femur,  dividing  the  muscles  and  opening  the  capsule 
freely.  The  knife  being  withdrawn,  the  excellent  saw  which  bears  Mr. 
Adams'  name  is  passed  along  the  wound  made  down  to  the  neck  of  the 
bone,  which  is  then  sawn  through.  After  sawing  for  about  four  or  five 
minutes,  the  limb  should  become  movable.  If  this  is  not  the  case,  the 
section  has  been  made,  not  through  the  neck  itself,  but  through  the 
junction  of  the  neck  and  shaft. 

In  order  to  bring  down  the  limb  completely,  the  contracted  tendons 
of  the  adductor  longus,  sartorius,  and  perhaps  the  rectus,  will  probably 
require  division  with  a  tenotome.  The  operation  should  be  conducted 
with  strict  antiseptic  precautions. 

The  limb  is  straightened  at  once,  and  put  up  with  a  long  outside 
splint — e.g.,  a  Desault's — and  a  little  morphia  given  if  needful.  There 
is  no  hgemorrhage,  and  the  wound  heals  quickly. 

This  operation  gives  good  results,  though,  as  stated  below,  I  i:)refer 


OSTEOTOMY  FOR  GENU  VALGUM.  723 

Gant's,  owing  to  its  greater  simplicity.  For  there  is  no  doubt  that  if 
the  bone  is  dense  from  previous  inflammation,  and  if  the  section 
trenches  upon  the  shaft  instead  of  going  through  the  neck  only,  the 
sawing  may  be  very  tedious.  Thus,  I  have  seen  two  cases  in  which  this 
took  over  half  an  hour. 

A  case  is  mentioned  in  a  report  from  a  committee  of  the  Belgian 
Academy  of  Medicine,  in  which  a  patient  who  had  been  submitted  to 
Adams'  operation  insisted  on  getting  up  on  the  twentieth  day. 
Haemorrhage  came  on  from  the  fragments  wounding  the  femoral  vessels 
or  some  large  branch.  The  femoral  was  tied  just  below  Poupart's 
ligament ;  the  haemorrhage  ceased,  but  free  incisions  were  required  for 
suppuration.  The  patient  viltimately  recovered.  The  same  committee 
reported  a  death  from  haemorrhage,  and  one  from  purulent  infiltration. 
No  bad  results  have,  I  believe,  followed  in  England. 

Gant's  Operation. — Here  the  shaft  of  the  femur  is  divided  just  below 
the  trochanters. 

Advantages. — The  operation  is  a  simpler  one  than  that  just  given,  as 
the  shaft  is  more  readily  reached  and  divided  than  the  neck.  Further- 
more, it  is  an  operation  of  wider  applicability,  for  it  is  suited  to  all 
cases,  not  onl}^  those  in  which  a  neck  remains,  but  those  more  common 
cases  of  ankylosis  after  hip-disease,  in  which  repair  has  taken  place  with 
partial  displacement  of  the  head,  or  what  remains  of  it.  The  fact  that 
in  these  cases  there  is  next  to  no  neck  left  to  divide,  makes  them 
unsuited  for  Mr.  Adams'  operation. 

A  long  tenotome  or,  better,  a  sharp-pointed,  narrow,  straight 
bistoury,  is  entered  just  below  the  great  trochanter,  and  made  to  divide 
everything  dowai  to  the  bone  as  it  is  lodged  upon  the  outer  aspect  of  the 
anterior  surface,  and  then  drawn  down  over  the  outer  surface  of  the 
shaft.  As  it  is  withdrawn,  the  wound  is  a  little  enlarged  downwards. 
The  saw  is  then  introduced  along  the  wound  well  down  to  the  bone,  and 
the  outer  two-thirds  of  this  sawn  through,  the  rest  being  effected  by 
snapping  the  bone  by  lateral  movements.  The  same  tendons  (p.  722) 
will  probabl}^  require  division. 

In  neither  case  is  it  any  practical  good  to  try  and  secure  a  false  joint. 


OSTEOTOMY  FOR   GENU  VALGUM   (Figs.   315-317)- 

Under  this  heading  the  following  operations  will  be  described  : — 

I.  Division  of  the  Shaft  of  the  Femur  from  the   Outer  Side 
(Fig.   317). 
IT.   Division  of  the  Lower  End  of  the  Femur  from  the  Inner 
Side,  just  above  the  Epiphysial  Line  (^^lacewen.  Fig.  317). 

III.  Division  of  the  Internal  Condyle  Obliquely  (Ogston). 

IV.  Division  of  the  Lower  End  of  the  Femur  and  the  Upper 
End  of  the  Tibia  above  and  below  their  respective 
Epiphyses  (Barwell). 

I.  Division  of  the  Shaft  of  the  Femur  from  the  Outer  Side  (Figs. 
315-317)- — '-L'l^e  limb  being  supported,  witli  the  knee  flexed,  on  a  sand- 
bag, an  incision  about  an  inch  and  a  half  long  is  made  at  a  right  angle 
to  and  down  to  the  bone  on  its  outer  side,  about  three  inches  above  the 
external  condyle.    The  knife— a  narrow,  straight  bistoury— should  go 


724 


OPERATIONS  ON  THE  LOWER  EXTREMITY. 


down  to  the  bone  deliberately,  and  cut  firmly  and  strongly  on  it, 
enlarging  the  wound  slightly  as  it  emerges,  in  order  that  the  soft  parts 
may  not  be  damaged  if  the  heel  of  the  saw  is  depressed,  and  that  there 
may  be  no  lip  of  tissues  to  hinder  the  escape  of  discharges.  The  saw 
or  chisel  is  then  introduced,  and  the  bone  divided  for  its  outer  two- 
thirds.  As  the  thicker  part  of  the  bone  is  on  the  outer  side,  as  soon  as 
this  is  divided  the  inner  third  usually  gives  way  readily  on  carrjang 
the  knee  and  leg  from  without  inwards.  But  the  operator  should 
continue  the  division  of  the  bone  till  he  can  feel  certain  that  two-thirds 
are  divided,  for  if,  after  dividing  only  half,  he  tries,  especially  in  the 
case  of  a  dense  bone,  to  fracture  the  rest  and  straighten  the  limb, 
either  great  or  prolonged  force  must  be  made  use  of,  leading  probably 


Fig.  315  * 


Fig.  316.* 


to  irritation,  cellulitis,  and  suppuration,  with,  perhaps,  necrosis ;  or  the 
saw  or  chisel  must  be  re-introduced,  a  point  to  be  alwa3^s  avoided  if 
possible,  as  the  difficulty  which  is  usually  met  with  in  hitting  off  the 
original  track  will  be  likely  to  lead  to  the  above  drawbacks. 

The  advantages  of  the  above  method  are  (i)  that  the  femur  is  divided 
at  a  much  narrower  part  than  in  the  supra-condyloid  operation  of 
Macewen,  and  that  thus  it  is  more  easily  and  quickly  done.  (2)  The 
bone  section  is  farther  away  from  the  epiphysis  and  the  line  of  the 
synovial  membrane,  in  case  subsequent  inflammation  takes  place. 
(3)  There  are  no  important  blood-vessels  near. 


*  Double  genu  valgum  treated  by  division  of  the  shaft  of  the  femur  from  the 
outside.  A  good  average  case,  both  as  to  its  severity  and  the  results  of  operation. 
Some  fiat  foot  remains  on  the  left  side. 


OSTEOTOMY  FOE  C4EXU  VALGUM. 


/-^5 


Fig 


II.  Division  of  the  Lower  End  of  the  Femur  from  the  Inner  Side, 
just    above    the    Epiphysial    Line   (supra-condyloid    of    Mace  wen*) 
(Fig.  317). — The  knee  being  flexed  and  sup- 
ported firmly  on  a  sand-bag,  the  skin  cleansed, 
the   position    of  the   adductor  tubercle  is  de- 
fined,  and    a    longitudinal    incision    about  an 
inch  long  (a  little  longer  than  the  breadth  of 
the  chisel  to  be  used)  is  made  down  to  the  bone 
at  a'  point  where  the  two  following  lines  meet 
— viz.,  one  drawn  transversely  a  finger's-breadth 
above  the  upper  margin  of  the  external  con- 
dyle, and  another  drawn  longitudinally  about 
half  an  inch  anterior  to  the  adductor  tubercle. 
The  scalpel  goes   at  once  down  to  the  bone. 
Superficial  veins   may  be    cut,  but  no  artery 
normalh'  distributed,  as  the  incision  is  below 
and  anterior  to  the  anastomotica  magna  and 
above  the  superior  internal  articular.     Before 
withdrawing    the    knife,    the    osteotome  f    is 
introduced   by  its  side  down  to  the  bone   in 
the  same  way  as  the   knife — i.e.,   parallel    to 
the  long  axis  of  the  limb — is  then  turned  at 
a  rig-ht  angle  to  it,  and  the  inner  two-thirds 
cut  through.     The  direction  of  the  bone-incision 
is  most    important.       The    surgeon   must  cut 
transversely  across  the  femur  on  a  level  with 
a  line  drawn   half  an  inch  above  the  top  of 
the  external  condyle.     This  incision  will  avoid 
the  epiphysis   and   synovial   membrane.      The 
line  of  the  former  may  be  usually  represented 
by  one  crossing  the  femur  at  the  level  of  the 
highest  point  of  the  femoral  articulating  sur- 
face, and   running  through    or  just    below  the    this  are  shown  Macewen's  and 
adductor  tubercle,  so  that,  the  incision  being    Of^^t^^^'^  operations.    The  ar- 
1       ,  ,1,1         I,!  -1        •         -H     row  indicates  the  direction  111 

an  inch  above  the  tubercle,  the  epiphysis  will 

be  cleared.  The  only  part  of  the  synovial 
membrane  which  is  as  high  as  the  bone  in- 
cision is  that  under  the  quadriceps,  which 
may  reach  in  the  adult  as  high  as  two  inches 
above  the  trochlear  surface.  It  is  somewhat 
triangular  in  shape,  its  base  being  at  the 
condvles,  and  it  generallv  tapers  to  the  middle 

line  as  it  ascends.     There  is  generally  a  quantity  of  fat  between  it  and 
the  bone.     The  spot  selected  by  Dr.  Mace  wen  for  his  incision  is  posterior 


The  transverse  line  on  the 
shaft  of  the  femur  shows  the 
site  of  division  of  the  bone 
from  the   outer  side.     Below 


which  the  osteotome  is  worked 
in  the  former.j  The  line  on 
the  tibia  shows  the  site  of 
division  of  the  bone  for  an 
ordinary  rickety  curve.  This 
curve  in  the  lower  third  should 
have  been  shown  more  marked. 
(After  Barker.) 


*   Osteotomy,  p.  120. 

t  In  adults  a  second,  or  even  a  third,  finer  instrument  may  be  used,  being  slipped 
in  over  the  first  as  this  is  withdrawn.     In  children  one  instrument  will  suffice. 

t  This  is  only  safe  in  a  child's  femur  ;  in  an  adult  the  osteotome  is  liable  to  be  broken 
if  pressed  against  the  bone  transversely  to  its  breadth,  and  must  only  be  worked  in  the 
direction  of  its  breadth.  This  point,  insisted  upon  by  Macewen,  has  been  kindly 
pointed  out  to  me  by  Mr.  Cathcart. 


■J 26  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

to  this  point.  As  in  a  valgous  limb  the  whole  internal  condj-le  is 
lowered,  a  line  drawn  transversely  from  the  adductor  tubercle  might 
land  the  operator  low  down  in  the  external  condyle.  The  osteotome 
must  be  driven  at  first  from  behind  forwards  and  to  the  outer  side  ;  it  is 
then  made  to  move  forwards  along  the  inner  border  until  it  comes  to  the 
anterior  surface,  when  it  is  directed  from  before  backwards  and  towards 
the  outer  posterior  angle  of  the  femur.  By  keeping  on  these  lines 
there  is  no  fear  of  injuring  the  artery.  The  hard  exterior  of  the  bone 
usually  resists  the  osteotome,  especially  in  adults,  but  several  strokes 
cause  it  to  penetrate  this  superficial  dense  portion,*  when  the  instru- 
ment will  pass  easily  through  the  cancellous  bone.  The  surgeon  will 
soon  recognise  by  touch  or  by  hearing  when  the  osteotome  meets  the 
hard  layer  on  the  opposite  side.  If  it  be  thought  desirable  to  penetrate 
this  outer  dense  part,  it  must  be  done  very  steadily,  so  as  to  check  any 
undue  impetus  on  the  part  of  the  osteotome.  A  sponge,  wrung  out  of 
I  in  40  carbolic  lotion,  is  then  placed  over  the  wound ;  the  surgeon, 
grasping  this  and  the  limb  with  his  left  hand,  and  taking  the  limb 
again  lower  down  with  his  right,  gives  the  extended  limb  thus  held  a 
quick  jerk  inwards ;  this  is  repeated  if  needful,  or  the  limb  may  be 
carried  outwards,  and  thus  broken  or  bent  sufficiently. 

III.  Division  of  the  Internal  Condyle  Obliquely  (Ogston  f) 
(Fig.  317). — This  operation,  though  a  great  improvement  on  the  opera- 
tions which  preceded  it — viz.,  opening  the  joint  and  sawing  off  the 
internal  condyle — has  been  entirely  replaced  by  others — viz.,  Macewen's, 
and  division  of  the  shaft  from  the  outer  side.  The  free  opening  of  the 
joint,  with  its  great  risks  if  the  wound  becomes  septic,  and  the  stiffness 
in  any  case,  have  led  to  this. 

The  limb,  being  flexed  and  supported  on  a  sand-bag,  a  long  tenotome 
is  entered  about  an  inch  above  the  upper  border  of  the  articialar  surface 
of  the  femur  exactly  in  the  middle  of  the  inner  aspect  of  the  thigh,  and 
with  it  an  incision  is  made  down  to  the  bone,  downwards  and  forwards, 
until  its  point  is  felt  beneath  the  skin  in  the  inter-condyloid  notch.  If 
the  patella  is  sufficiently  dislocated  outwards,  the  point  of  the  saw  can 
be  felt  in  the  groove  ;  but  if  the  patella  is  not  so  displaced,  it  must  be 
lifted  up  and  the  point  of  the  saw  passed  iinder  it.  The  knife  must  cut 
down  upon  the  bone  decidedly,  and.  as  it  is  withdrawn,  it  must  enlarge 
the  opening  for  the  saw.  An  Adams'  saw  is  then  thrust  along  the 
knife  track,  and  the  inner  condyle  sawn  off  from  before  backwards. 
The  bone  must  be  sawn  almost  completely  through,  the  strokes  being 
increasingly  careful  as  the  back  of  the  bone  is  reached.  When  the 
section  is  thought  to  have  nearlj^  reached  this  point  the  saw  is  withdrawn, 
the  wound  covered  with  a  carbolised  sponge,  and  the  extended  leg  forced 
strongly  inwards.  The  condyle  now  slips  up  somewhat  on  the  cut 
surface  of  the  femur. 

IV.  Division  of  Tibia  as  well  as  Femur. — The  division  of  the  tibia 
(and  the  fibula  also)  as  well  as  the  femm-  has  been  advocated  by  Mr. 

*  The  osteotomes  must  be  bevelled  on  both  sides,  wedge-like,  and  sufficiently  trust- 
worthy for  hardness  and  toughness,  points  only  to  be  secured  by  getting  them  of 
first-rate  and  painstaking  makers.  Dr.  Macewen's  test  is  as  follows  :  If  the  instrument 
will  neither  turn  nor  chip  in  penetrating  the  thigh-bone  of  an  ox,  it  is  well  suited  for 
cutting  human  bones. 

t  Edin.  Med.  Journ.,  March  1877, 


OSTEOTOMY  OF  THE  TIBL\. 


727 


Barwell  and  others.  Tn  the  majority  of  cases,  though,  at  first  sight, 
there  may  seem  to  be  one  striking  curve  localised  to  one  spot,  a  closer 
examination  shows  that  in  reality  several  cui"\-es  are  present,  and  often 
of  different  kinds,  antero-posterior  as  well  as  lateral,  diffused  over  the 
whole  shaft  rather  than  limited  to  one  end.  In  these  cases,  rectifying 
one  curve  often  makes  the  others  more  prominent.  Multiple  osteotomies 
are  required  here,  the  femur  and  the  tibia  each  requiring  division  in 
two  places.  In  one  very  aggi-avated  case  of  genu  varum,  in  which 
the  limbs  (when  the  ankles  were  placed  together)  formed  a  circle, 
Prof.  Macewen  performed  ten  osteotomies  at  one  time  {loc.  supra  cit.. 
Figs.  40  and  41  j.  In  such  severer  cases  most  operators  will  prefer  to 
straighten  one  side  at  a  time. 

Operation. — An  incision  is  made  as  at  p.  728  over  the  inner  surface 
of  the  tibia  just  below  its  tubercle,  and  the  bone  divided  with  an  osteo- 
tome or  saw  from  within  outwards.  The  tissue  on  the  anterior  part 
just  below  the  tubercle  is  much  the  densest.  The  section  of  the  tibia 
should  be  made  on  the  same  occasion  as  that  of  the  femiu-. 

However  an  osteotomy  wound  is  made,  whether  with  saw  or  chisel, 
no  attempt  should  be  made  to  close  it,  but  a  little  iodoform  dusted  on 
and  gauze  dressings  applied.  It  is  very  rarely  needful  to  remove  these 
before  the  tenth  or  fourteenth  day.  If  a  stain  come  through,  it  should 
be  dusted  with  iodoform  and  a  little  fresh  dry  dressing  applied. 

Prof.  Macewen  uses  a  splint  consisting  of  a  long  outside,  and  a  short 
back,  with  a  foot-piece.*  I  have  usually  preferred  plaster  of  Paris. 
applied  by  Mr.  Croft's  method,  for  children,  amongst  whom  my  experi- 
ence has  mainly  lain.  It  makes  even,  steady  pressure  upon  the  muscles 
around  the  wound,  keeping  them  and  it  at  rest,  and  it  allows  the  patient 
to  be  more  easily  moved,  especially  when  both  limbs  have  been  operated 
on.  The  outer  piece  of  flannel  should  be  brought  high  iip.  to  the  level 
of  the  iliac  crest,  so  as  to  better  command  the  muscles  which  disturb  the 
upper  fragment.  Where  the  child  is  likely  to  be  restless,  a  long  outside 
splint  should  also  be  applied.  I  make  use  of  this  in  all  my  cases  of 
osteotomy  of  the  femur.  However  the  limb  is  put  up,  the  bandages 
must  be  applied  firmly  and  evenly,  but  without  undue  tightness.  The 
condition  of  the  toes,  as  to  colour  and  movement,  must  be  carefully 
watched.  When  the  dressings  are  removed  at  the  end  of  ten  or  fourteen 
days  I  like  to  have  an  angesthetic  given,  and  to  rectify  any  slight 
remaining  deformity. 

The  splints  or  plaster  of  Paris  should  be  continued  for  six  weeks, 
when  the  limb  may  be  only  supported  with  sand-bags  if  the  union  is 
firm.  Passive  and  active  movement  may  be  now  allowed.  In  about 
three  months  the  patient  may  be  got  up,  with  a  stick,  under  observa- 
tion. Before  the  patient  leaves  the  surgeon's  eye,  care  should  be  taken 
that  he  can  bend  his  knee  well. 

OSTEOTOMY    OF    THE    TIBIA. 

This  may  be  (A)  Simple  Division  or  (B)  Cuneiform — i.e.,  the  taking 
out  of  a  wedge  of  bone.     The  former  of  these,  a  very  simple  operation^ 

*  Prof.  Macewen  advises  the  use  of  a  mattress  consisting  of  four  parts,  the  two 
centre  pieces  corresponding   to  the  glutaeal  region,  and  easily  removed  to  admit  of 

the  introduction  of  the  bed-pan. 


728  OPERATIONS  OX  THE  LOWER  EXTREMITY. 

will  suffice  for  the  ordinarily  curved  tibije,  where  the  bone  is  bent 
laterally,  and  the  bend  is  most  marked  at  the  junction  of  the  middle  and 
lower  thirds.  Cuneiform  osteotomy  will  be  required  when  the  bending 
is  not  only  lateral,  but  antero-posterior  as  well. 

A.  Simple  Osteotomy  of  the  Tibia  (Fig.  317). — The  parts  being 
cleansed,  and  the  limb  resting  on  its  outer  side  on  a  firm  sand-bag,  the 
surgeon  notes,  at  the  anterior  and  inner  margins  of  the  tibia,  the  spot 
where  the  curve  is  sharpest.  Fixing  his  left  index  over  the  inner 
margin,  he  enters  a  long  tenotome  or  narrow  bistoury  exacth^  over  the 
crest  of  the  tibia,  sends  it  down  under  the  skin  over  the  inner  surface  of 
the  bone  till  its  point  is  felt  just  beneath  the  finger  ;  it  is  here  pushed 
through  the  skin  to  make  a  counter-puncture  for  drainage.  The  knife, 
hitherto  held  horizontally,  is  now  turned  vertically  and  cuts  firmly  on 
the  bone,  dividing  the  periosteum,  thick  in  these  cases,  in  one  line  right 
across  the  inner  surface  of  the  tibia.  As  the  knife  is  withdrawn  it  is 
made  to  enlarge  the  wound  of  entrance  slightly,  to  make  room  for  the 
saw.  This  (Adams')  is  now  introduced  in  the  same  way  as  the  knife, 
carried  horizontally  down  to,  but  not  through,  the  puncture  through  the 
skin  of  the  inner  border  of  the  tibia.  The  left  index  keeping  guard 
over  the  tibial  artery,  the  saw  is  turned  towards  the  bone  and  cuts 
through  the  inner  two-thirds  of  it.  The  entrance  of  the  saw  into 
cancellous  tissue  can  be  known  by  the  diminution  of  resistance  and  the 
increased  bleeding  which  often  occur,  but  the  best  test  of  the  depth  to 
which  the  operator  has  arrived  is  the  depth  of  the  groove  in  which  the 
saw  has  sunk.  When  the  bone  is  sawn  sufficiently,  carbolised  lint  is 
placed  on  the  wound,  and  the  surgeon,  firmly  placing  his  two  hands, 
close  together,  immediately  above  and  below  the  wound,  sharply  carries 
the  lower  fragment  outwards.  If  the  saw  has  been  sufficiently  used,  the 
tibia  snaps  distinctl}',  while  the  fibula  3'ields  with  a  "greenstick" 
sensation.  Great  care  must  be  taken  to  exert  the  force  just  on  the 
sawn  portion,  or  the  ligaments  of  the  ankle  or  the  superior  tibio-fibular 
joint  may  be  strained  and  damaged.  Attention  has  already  been  drawn 
to  the  need  of  using  the  saw  sufficientlv,  otherwise  the  parts  will  be 
bruised  and  damaged  in  the  futile  attem^Dts  at  fracture. 

B.  Cuneiform  Division  of  the  Tibia. — Bemoval  of  a  "Wedge. — 
The  parts  being  duly  cleansed,  an  incision  is  made  along  the  crest  of 
the  tibia  equal  to  the  base  of  the  wedge  which  is  going  to  be  removed. 
It  need  not  be  longer,  as  the  skin  can  be  pulled  up  and  down  if 
needful.  The  periosteum  is  then  divided  cleanh',  and  separated  from 
the  tibia  with  curved  scissors.  This  membrane  toeing  held  out  of  the 
way  with  retractors,  a  wedge  is  next  removed  with  an  osteotome  or  a 
narrow  and  sharp  chisel  but  little  bevelled.  The  gap  can  then  be 
enlarged  hy  removing  from  either  side  further  shavings  as  required. 
Occasionally  free  haemorrhage  takes  place  from  the  medullar}^  artery, 
but  this  soon  stojos  with  firm  sponge  pressure.  The  limb  is  now 
straightened  b}''  bending  the  lower  fragment  upwards*  so  as  to  bring 
the  surfaces  of  the  gap  in  contact.  The  periosteum  at  the  upper  and 
lower  angles  of  the  wound  may  be  closed  with  chromic  catgut  sutures 
cut  short.     The  skin  wound  is  also  closed  above  and  below,   but  left 

*  Aided  by  movements  in  the  opposite  direction,  and  from  side  to  side  if  needed. 
The  fibula  is  broken  subcutaneouslv. 


OSTEOTOMY  OF  THE  TIBIA. 


729 


open  in  the  centre  for  drainage.  In  this  and  the  preceding  operation 
sufficiently  thick  dressings  should  be  applied  to  meet  any  oozing  from 
the  bone.  Plaster  of  Paris  (p.  727)  or  back  and  side  splints  should 
be  applied. 

Cuneiform  Division  of  the  Femiir. — In  cases  where  the  curve  is 
chieily  an  antero-posterior  one  afiecting  the  middle  of  the  shaft,  the 
deformity  can  only  be  properly  removed  by  taking  out  a  wedge.  This 
is  done  on  the  lines  given  above.  An  incision  is  made  through  skin  and 
quadriceps  down  to  the  periosteum,  and  a  second  firm  cut  exposes  the 
bone.  The  di\'ided  muscle  is  then  drawn  aside  with  Spencer  Wells's 
forceps  applied  to  bleeding  points,  and  the  periosteum  separated  on 
each  side  down  to  the  linea  aspera.  A  wedge  is  then  removed  and  the 
bone  straightened.  The  bleeding  is  often  free  from  the  nutrient  artery, 
but  this  is  arrested  when  the  bone  is  straightened.  The  greatest  care 
must  be  taken  to  keep  within  the  periosteum,  the  soft  parts  being  thus 
uninjured,  and  to  adopt  strict  aseptic  precautions. 

Causes  of  Death  and  Failure  after  Osteotomy. 

I.  Septic  troubles. — Such  a  case  will  be  found  published  in  the  Clin. 
Soc.  Trans.,  vol.  xii.  p.  27.  It  is  too  probable  that  other  operators  have 
not  been  so  candid.  2.  Carboluria. — A  case  of  rapidly  fatal  carbolic 
intoxication  after  antiseptic  osteotomy  of  the  tibia  will  be  found  in  the 
same  Transactions,  vol.  xiv.  p.  201.  3.  Haemorrhage. — At  least  one 
case  has  occurred  of  haemorrhage  from  the  femoral  and  one  from  the 
anastomotica  after  division  of  the  femur.  I  have  also  heard  of  a  case 
in  which  the  posterior  tibial  was  injured  in  osteotomy  of  the  tibia. 
4.  Necrosis. 

This  occurred  in  one  of  my  cases  of  osteotomy  of  the  femur,  a  lad  of  16.  It  was 
noticed  that  he  took  the  anaesthetic  (ether)  verv  badly,  and  when  the  eflEects  of  this 
had  passed  off  he  was  extremely  restless  and  excited  for  forty  minutes.  To  this  I 
attribute  the  mischief  that  followed.  Suppuration  with  a  very  unhealthy  state  of 
the  wound,  oedema,  and  cellulitis  ensued,  leading  to  necrosis.  Eventually  the  lad 
recovered,  but  required  a  cork  sole  of  two  inches.  The  presence  of  a  pre-systolic 
murmur  perhaps  accounted  for  the  effects  of  the  anaesthetic. 

5.  Division  of  the  tibialis  anticus  tendon. 

This  occurred  in  an  osteotomy  of  the  tibia  performed  by  one  of  my  dressers,  who 
forgot  how  close  the  tendon  lies  to  the  outer  side  of  the  crest.  The  cut  ends  were 
joined  by  chromic  catgut,  and  the  action  of  the  muscle  was,  afterwards,  unimpaired. 


CHAPTER    IX. 
TENOTOMY. 

TENOTOMY  OF  THE  TENDONS  ABOUT  THE  FOOT.  - 
SYNDESMOTOMY.— TENOTOMY  OF  HAMSTRING 
TENDONS.— TENOTOMY    OF    THE    STERNO-MASTOID. 

TENOTOMY    OF    TENDONS    ABOUT    THE    FOOT. 

Division  of  Tibial  Tendons. 

Tibialis  Anticus. — This  is  usually*  divided  where  it  is  crossing  the 
ankle-joint  from  without  inwards,  a  little  above  its  insertion  into  the 
internal  cuneiform.  It  has,  here,  the  dorsalis  pedis  vessels  on  its  outer 
side,  but  separated  from  it  by  the  extensor  proprius  hallucis. 

The  surgeon  usually  stands  on  the  opposite  side  of  the  leg  to  that  of 
the  tendon,  either  facing  the  trunk  or  with  his  back  towards  it,  as  is 
most  convenient.  The  assistant  stands  opposite  to  him,  grasping  the 
foot  with  one  hand  and  the  leg  with  the  other.  The  position  of  the 
tendon  is  made  out  by  making  it  tense  by  abducting  and  extending  the 
foot.  The  surgeon  then  notes  the  position  of  the  anterior  tibial  vessels, 
defines  exactly  the  width  of  the  tendon,  and  places  the  tip  of  his  index 
finger  exactly  on  the  side  of  the  tendon  farthest  from  him.  He  then 
inserts  the  tenotomy  knife  vertically  close  to  the  tendon  on  the  side 
nearest  to  him ;  sinks  it  lightly  till  he  feels  sure  it  is  on  a  level  lower 
than  that  of  the  tendon ;  then  sends  it  horizontally  across  till  he  feels 
its  point  just  under  his  index  finger,  and,  having  turned  its  edge 
upwards,  finally,  by  a  series  of  light  levering  or  sawing  movements,  cuts 
through  the  tendon.  The  assistant  relaxes  the  foot — i.e.,  adducts  and 
bends  it  upA\'ards — when  the  knife  is  first  introduced,  but  places  it  on 
the  stretch  at  a  signal  from  the  surgeon.  Finally,  as  soon  as  the  com- 
pletion of  the  creaking  sound  and  the  sudden  snap  denote  the  division 
of  the  tendon,  the  foot  is  again  relaxed.  A  small  pad  of  gauze  being  at 
once  applied,  the  foot  is  put  up  in  the  everted  position.  For  this 
purpose  nothing  is,  to  my  mind,  so  simple  and  efficient  as  a  well-padded 

*  For  tenotomy  of  this  and  the  tibialis  posticus  I  greatly  prefer  the  site  given 
under  Syndcsmotomy. 


TENOTOMY.  73 1 

splint  of  the  proper  width,  with  two  notches  at  its  lower  end,  the  upper 
end  being  just  below  the  knee  in  infants,  and  the  lower  projecting  two 
inches  and  a  half  below  the  foot.  The  splint  is  applied  to  the  outer  side, 
the  leg  being  first  rolled  in  a  flannel  bandage  to  prevent  pressure-sores. 

Tibialis  Posticus. — It  is  usually  recommended  to  divide  this  an  inch 
and  a  half  or  two  inches  above  the  internal  malleolus.*  The  tendon  is 
here  separated  from  the  posterior  tibial  vessels  by  the  flexor  longus 
digitorum. 

The  surgeon  and  his  assistant  occupying  positions  as  at  p.  730,  the 
exact  site  of  the  tendon  is  defined,  if  possible,  by  abducting  and 
bending  down  the  foot.  In  fat  infants  it  is  often  quite  impossible  to  feel 
the  tendon,  and  in  these  cases  a  spot  midway  between  the  anterior  and 
internal  borders  of  the  leg  will  be  the  best  guide,  as  denoting  the  inner 
margin  of  the  tibia.  The  surgeon  then  introduces  a  sharp  tenotome  so 
as  just  to  touch,  if  possible,  the  inner  margin  of  the  tibia,  taking  care 
to  sink  the  blade  sufficiently  to  open  the  sheath  freely.  This  being 
done,  a  blunt  tenotome  is  introduced  through  the  same  opening,  and 
pushed  under  the  tendon  ;  the  edge  being  then  turned  towards  it,  and 
the  tibia  used  as  a  fulcrum,  the  tendon  is  severed,  together  with  that  of 
the  flexor  longus  digitorum.  The  assistant  first  relaxes  and  then 
extends  the  tendon,  as  advised  above  (p.  730). 

If  the  artery  be  cut,  as  shown  by  the  jetting  hemorrhage  and  the 
blanching  of  the  foot,  firm  pressure  must  be  applied,  the  foot  being 
first  bandaged.  No  eversion  mvist  be  practised,  but  the  foot  put  up  in 
the  faulty  position  for  about  a  week. 

Plantar  Fascia.f — This  may  be  divided  just  below  its  origin  from  the 
OS  calcis,  or  in  advanced  cases  close  to  the  transverse  crease,  which  is 
here  found  in  the  sole.  With  regard  to  this  fascia,  the  surgeon  should 
not  tie  himself  down  to  any  fixed  spot,  but  divide  resisting  bands  when- 
ever they  are  felt. 

Syndesmotomy. — This  term  has  been  introduced  by  Mr.  R.  AY. 
Parker  {Con<jenital  Club-foot,  p.  62  et  jKff^sim),  who  believes  that  in  many 
cases — e.g.,  severe  ones,  cases  not  treated  in  early  life,  and  in  some 
relapsed  cases — the  foot  cannot  be  rectified  even  by  multiple  tenotomy. 
He  attributes  this,  not  to  adhesions,  but  to  the  faulty  shortness,  and 
unj-ielding  nature  of  the  ligaments.  Chief  amongst  these,  in  eqiiino- 
varus,  are  the  ligaments  about  the  astragalo-scaphoid  joint.  '"  In  these 
cases  there  is  a  capsule  made  up  above  and  internally  by  a  blending 
together  of  the  superior  astragalo-scaphoid  ligament  with  fibres  from 
the  anterior  ligament,  and  the  anterior  portion  of  the  deltoid  ligament 
below  with  fibres  from  the  inferior  calcaneo-scaphoid  ligament.  To 
these  are  united  fibrous  expansions  of  the  tendons  of  the  anterior  and^ 
posterior  tibial  muscles  ;  together  they  form  an  unyielding  capsule  ot 
great  strength,  which  is  attached  to  the  several  bones,  not  in  the  usual 
manner,  but  in  adaptation  to  their  altered  relative  positions.  This  I 
would  name  the  'astragalo-scaphoid  capsule.'"  Mr.  Parker  gives  direc- 
tions for  dividing:  this  structure  which  can  be  made  to  combine  division 

*  The  tendon  is  here  rather  farther  from  the  artery,  and  the  surgeon  will  be  above 
the  commencement  of  its  synovial  sheath,  in  which  it  traverses  the  internal  annular 
ligament. 

t  Division  of  the  palmar  fascia  is  fully  described  at  p.  22,  Vol.  I. 


732  OPERATIONS  ON  THE  LOWER  EXTREMITY. 

of  the  tibial  tendons  in  a  manner  which  I  consider  far  more  satisfactory 
than  that  ah'eady  given.  Since  reading  his  book  I  have  adopted  his 
method  in  eighteen  cases  with  good  results.  I  much  prefer  it  to  that 
usually  followed. 

The  site  chosen  for  this  combined  division  of  tendons  and  ligaments 
is  a  little  below  and  anterior  to  the  tip  of  the  internal  malleolus.* 
Other  guides  are  the  site  of  the  astragalo-scaphoid  joint,  and  in  older 
cases  the  transverse  crease  which,  running  down  on  to  the  sole,  denotes 
the  inversion  of  the  foot.  Two  tenotomes  are  required,  one  of  ordinary 
pattern,  and  one  curved,  somewhat  sickle-shaped,  and  with  a  cutting 
blade  about  half  an  inch  in  length. 

The  surgeon  notes  the  position  of  the  arteries,  and  the  lines  along 
which  the  tibial  tendons  are  curving  towards  the  internal  cunei- 
form. Having  marked,  at  the  spot  above  given,  the  position  of 
these  tendons,  he  enters  a  sharp-pointed  tenotome,  the  parts  being 
relaxed,  just  above  the  posterior  tibial  artery,  and  pushes  it  outwards 
on  to  the  dorsum  to  a  spot  just  short  of  the  dorsalis  pedis  artery,  the 
knife  travelling  just  beneath  the  skin  to  make  a  path  for  the  next  in- 
strument, which  does  the  work.  The  curved  tenotome  is  then  inserted 
under  the  skin,  and  pushed  on,  flat-wise,  till  its  tip  can  be  felt  over  the 
tibialis  anticus ;  it  is  then  turned  blade  downwards,  the  tibialis  anticus 
is  felt  to  give  way,  and,  as  the  knife  cuts  on  the  subjacent  bones  and 
cartilages,  the  ligaments  are  felt  to  yield  to  it,  while,  as  it  is  withdrawn, 
its  edge  divides  the  tibialis  posticus. 

The  internal  saphena  vein  would  seem  to  lie  under  this  incision,  but 
the  haemorrhage,  never  marked,  is  usually  very  slight.  As  I  have 
stated,  the  results  in  the  eighteen  cases  in  which  I  have  used  this 
method  have  been  excellent,  though  in  two  I  was  unable  to  satisfy 
myself  that  the  tibialis  posticus  had  given  way  ;  in  one  it  was  certainly 
notched,  and  jdelded  subsec[uently. 

As  here  the  incision  is  made  from  the  skin  down  upon  the  tai'sal 
bones,  I  have  used  irrigation  with  lotion  of  mercury  perchloride  or 
carbolic  acid.  The  wound  is  a  comparatively  free  one,  but  quite 
subcutaneous,  starting  from  a  mere  puncture. 

As  I  have  stated,  I  prefer  to  put  up  a  case  of  talipes  varus  after 
syndesmotomy,  with  the  foot  everted  at  once,  on  a  notched  splint  like 
a  Dupuj'tren's,  but  applied  to  the  outer  side.  If  the  tendo-Achillis 
requires  division,  this  is  done  in  a  few  davs,  and  the  foot  put  up  for 
about  a  week,  in  good  position,  by  Mr.  Croft's  method  of  plaster  of 
Paris.  After  this,  in  early  life,  the  foot  must  be  manipulated  daily  by 
the  surgeon  for  a  while,  and  several  times  daily  by  the  friends,  the 
surgeon  seeing  it  at  first  everj^  other  da3^  If  these  manipulations  are 
persevered  with  daily  by  the  mother  or  nurse,  and  the  case  kept  under 
the  surgeon's  eye,  expensive  boots  and  other  apparatus  will  not  be 
needed  in  children. 

Tendo-Achillis. — This  should  be  divided  half  an  inch  above  its 
insertion  in  an  infant,  and  an  inch  and  a  half  in  an  adult. 

The  foot  and  leg  being  turned  well  over  on  to  the  outer  side,  and  the 
tendon  being  relaxed  by  the  assistant  bending  the  foot  downwards,  the 


*  Mr.  Parker  Qlor.  supra  cit.,  p.  78)  shows  that  Velpeau  and  Syme  pointed  out  the 
possibility  of  dividing  the  tendon  of  the  tibialis  posticus  here. 


TENOTOMY   OF  THE  HAMSTRINGS.  733 

margins  of  the  tendon  ai'e  accurately  defined.  The  knife  is  then  intro- 
duced vertically  close*  to  the  inner  side  of  the  tendon  till  it  reaches 
a  sufficient  depth  to  ensure  being  beneath  it;t  it  is  then  pushed  hori- 
zontall}"  across  under  the  tendon  till  it  is  felt  under  the  skin  by  the  left 
index  finger,  which  accurately  marks  out  the  outer  limit  of  the  tendon ; 
the  blade  is  then  turned  towards  the  tendon,  which  being  at  the  same 
time  put  on  the  stretch  b}'  bending  up  the  foot,  is  divided  by  a  series 
of  levering  movements  of  the  handle.  Creaking  movements,  followed 
by  a  sudden  snap  or  thud,  denote  complete  division,  when  the  tendon 
is  to  be  at  once  relaxed  and  the  knife  brought  out  horizontallv. 

The  Peronaei. — The  peronseus  longus  and  brevis  occasionally  require 
division.  They  may  be  divided  simultaneously  by  entering  a  tenotome 
between  them  and  the  bone  about  two  inches  above  the  external  malle- 
olus. Immediately  above  this  process  the}^  are  more  under  cover  of  the 
bone.  If  divided  below  it,  their  sj^novial  sheath  would  be  opened; 
this  is  to  be  avoided  in  case  of  sepsis. 

TENOTOMY    OF    THE    HAMSTRINGS. 

The  patient  being  rolled  two-thirds  on  to  his  face,  the  surgeon  stands 
on  the  same  side  as  that  on  which  lies  the  tendon  to  be  divided,  facing  or 
turned  from  the  trunk  as  is  most  convenient.  An  assistant  stands 
opposite  to  him  to  relax  and  tighten  the  tendon. 

Biceps. — The  exact  limits  of  the  tendon  being  defined,  the  surgeoa 
introduces  a  sharp  knife  close  to  the  inner  side  of  the  biceps,  so  as  to 
get  between  it  and  the  external  popliteal  nerve,  and  having  sunk  it 
sufficiently  to  get  beneath  the  tendon,  pushes  the  knife  outwards,  hori- 
zontally, till  it  is  felt  beneath  the  skin  under  the  left  index,  which  marks 
the  outer  limit  of  the  tendon.  The  edge  being  turned  towards  this,  the 
tendon  is  extended  by  the  assistant,  and  divided  in  the  usual  way. 
When  this  is  done,  the  limb  is  flexed  and  the  knife  withdrawn 
horizontally. 

When  the  tendon  is  cut,  a  cord  often  rises  up  close  to  it.  This  is  the 
nerve,  and  the  knife  must  on  no  account  be  re-introduced. 

If,  after  tenotomy  in  long-standing  cases,  any  contracted  bands  of 
fascia  do  not  give  way  to  extension,  which  thej'  will  generally  do,  it  is 
wiser  to  make  a  small  open  wound,  antiseptically.  and  divide  them  thus, 
that  the  surgeon  may  be  certain  as  to  what  he  is  dividing.  The  wound 
is  united  afterwards  with  one  or  tivo  horsehair  sutures. 

Semi-tendinosus  and  Semi-membranosus. — These  tendons  can  be 
divided  in  the  same  way  as  the  biceps.  A  contracted  knee  can  generally 
be  straightened  after  division  of  the  biceps  and  semi-tendinosus.  If  it 
is  needful  to  insert  the  knife  more  deeply  so  as  to  divide  the  semi- 
membranosus, it  woitld  be  Avell  to  use  a  blunt-pointed  tenotome,  or 
to  operate  through  an  open  incision. 

In  one  case  of  a  girl  of  16,  after  I  had  divulcd  the  biceps  and  semi-tendinosus,  I 
had  dipped  the  point  of  the  knife  a  little  more  to  ensure  division  of  the  deeper  and 

*  So  as  to  avoid  the  posterior  tibial  artery. 

t  Young  operators  often  do  not  insert  the  knife  suflBciently  deep ;  they  thus,  when 
it  is  pushed  across,  get  into  the  tendon  instead  of  beneath  it,  and  so  divide  it 
incompletely. 


734  OPERATIONS  ON  THE  LOWER  EXTREMITi^ 

larger  semi-membranosus.  Most  profuse  liEemorrhage  followed  from  the  superior 
internal  articular  vessels.  Firm  padding  and  bandaging  were  applied,  and  the  limb 
put  up  in  the  faulty  position  for  four  days.     No  recurrence  of  the  bleeding  took  place. 


TENOTOMY    OF    THE    STERNO-MASTOID. 

The  two  heads  are  best  divided  from  separate  punctures  just  above 
the  clavicle.  The  muscle  being  made  prominent,  by  one  assistant  mani- 
pulating the  head  and  another  depressing  the  shoulder,  the  surgeon, 
standing  facing  the  patient  on  the  side  to  be  operated  upon,  defines  the 
limits  of  the  inner  border  of  the  sternal  tendon,  opens  the  fascise 
sufficiently  freeh^  here,  and  then,  taking  a  blunt-pointed  tenotome, 
insinviates  it  horizontally  behind  and  close  to  the  tendon  till  it  is  felt 
just  beneath  his  left  index  finger,  which  is  placed  at  the  outer  margin ; 
the  edge  is  then  turned  towards  the  tendon,  and  divides  it.  It  is  with- 
drawn with  the  usual  precautions.  The  clavicular  tendon  is  divided  in 
a  similar  way  through  another  puncture. 

Care  must  be  taken  to  avoid  the  anterior  jugular,  which  runs  out- 
wards under  the  muscle  a  little  above  the  clavicle,  and  the  external 
jugular,  which  lies  at  a  varying  level  close  to  the  outer  border  of  the 
clavicular  head.  If  a  sharp  tenotome  were  dipped  too  deepl}^  the  internal 
jugular  might  also  be  wounded. 

If  any  smart  venous  haemorrhage  occur,  a  pad  of  dry  gauze  should  be 
firmly  bandaged  on. 

The  open  method,  in  which  the  muscle  is  divided  on  a  director  after 
a  skin  incision  has  been  made  transversely  over  its  lower  third,  and  its 
borders  defined,  is  advised  by  some  as  allowing  of  every  step  being  seen, 
avoiding  abnormal  vessels,  and  securing,  not  onlj'  complete  division  of 
the  muscle,  but  also  of  any  fascial  bands.  These  I  have  very  rarely  met 
with.  The  scar  is  said  to  be  slight  if  the  wound  is  sutured  and  carefully 
dressed  (Tubby,  Orthopcedic  Surgery,  p.  202). 

Causes  of  Failure  after  Tenotomy. 

I.  Septic  troubles.  These  usually  arise  from  the  use  of  dirty  instru- 
ments which  clean  themselves  at  the  patient's  expense,  or  from  making 
an  open  wound.  2.  Incomplete  division  of  the  tendon.  3.  Division  of 
important  structures — e.g.,  the  tibial  arteries,  the  external  popliteal  nerve, 
the  anterior  or  internal  jugular  veins.  4.  Non-union  of  the  tendon. 
5.  Mal-union  of  the  tendon — i.e.,  adhesions  formed  by  it  to  adjacent 
structures,  e.g.,  its  sheath  or  a  bone.  These  must  both  be  extremely 
rare.     6.  Breaking  off  the  point  of  the  tenotome,  usually  against  a  bone. 


CHAPTER   X. 
OPERATIONS    ON    NERVES. 

NERVE  SUTURE. — NERVE  STRETCHING. 

NERVE  SUTURE. 

This  may  be  required  as  a  primary  or  secondary  operation.  The 
latter  is  accompanied  with  much  more  difficulty,  owing  to  the  greater 
retraction  of  the  nerve  ends,  their  bulbous  or  filiform  extremities,  their 
being  often  buried  in  scar  tissue  or  matted  b}^  it  to  neighbouring  parts 
— e.g.,  tendons  and  fasciae  ;  to  which  must  be  added  other  unfavourable 
points — e.g.,  the  atrophy  and  fatty  change  in  the  muscles  and  the  stiff- 
ness of  the  joints. 

Primary  Suture.* — As  the  mode  of  uniting  nerves  will  be  fully 
described  under  the  head  of  secondary  nerve  suture,  the  more  difficult 
proceeding,  it  need  not  be  repeated  here.  It  only  remains  to  emphasise 
the  importance  of  alwaj^s  resorting  to  it,  and  not  trusting  to  spon- 
taneous cure.  Howell  and  Huber  (Jourii.  of  Physiol.,  vol.  xiii.)  have 
collected  eighty-four  cases  of  primary  nerve  suture ;  42  per  cent,  of 
these  were  successful,  40  per  cent,  were  improved,  and  in  the  remaining 
18  per  cent,  the  operation  failed.  The  results  of  secondary  suture  can 
never  be  so  good  as  these. 

Secondary  Suture. — The  operation  on  the  median  or  ulnar  will 
be  considered,  as  these  are  so  commonly  injured.  The  following  steps 
must  be  remembered  :  (i)  Finding  the  nerve  ends.  (2)  Freeing  and 
refreshing  them.  (3)  Passing  the  sutures,  and  bringing  the  ends  into 
apposition.     (4)  Dressing  the  wound,  and  the  after-treatment. 

I.  Finding  the  Nerve  Ends. — With  accurate  anatomical  knowledge 
this  is  QQS,j.  An  Esmarch's  bandage  does  not  appear  to  be  necessary, 
as  the  incision  is  made  parallel  with  the  vessels,  and  the  use  of  one 
leads  to  oozing  afterwards.  Mr.  Bowlby  {loc.  siqu'a  cit.,  and  Hunt. 
Lect.,  Lancet,  July  16,  1887)  thinks  that  the  parts  should  be  rendered 
bloodless.     If  this  course  is  adopted  care    must  be   taken   to   provide 

*  Much  information  on  the  subject  of  primary  and  secondary  suture  will  be  found 
in  the  section  on  Suture  of  Tendons  (p.  30,  Vol.  I.). 


JlG  OPERATIONS  ON   THE  LOWER  EXTREMITY. 

sufficient  drainage,  and  the  upper  bandage  must,  if  possible,  be  applied 
sufficiently  far  from  the  wound  not  to  interfere  with  pressing  down  the 
parts  when  the  nerve  ends  are  approximated.  If  bandages  are  em- 
ployed, the  parts  should  be  made  absolutely  evascular ;  careless  applica- 
tion will  only  cause  most  annoying  oozing.  An  incision,  two  to  three 
inches  long,  being  made  over  and  parallel  to  the  nerve  ends,  the  deep 
fascia  and  any  scar  tissue  are  carefully  divided  and  the  ends  found,  the 
upper  bulbous  and  the  lower  filamentous  usually,  and  not  always  in  a 
line  wdth  each  other.  If  the  distal  end  be  very  difficult  to  find  owing 
to  its  filiform  shape  and  its  being  embedded  in  scar  tissue,  the  w^ound 
should  be  prolonged,  the  nerve  found  lower  down,  and  traced  up  to  the 
distal  end.  The  ends  are  next  freed  from  the  adjacent  parts,  and 
cleared  of  cicatricial  tissue. 

2.  Besedion  of  the  Nerve  F/iids. — This  is  best  effected  by  sharp 
scissors,  with  one  stroke,  and  without  any  bruising.  If  the  nerve  is 
held  with  forceps,  these  must  hold  the  sheath  only.  In  case  of  primary 
suture,  jagged  or  frayed  ends  need  only  be  pared  sufficiently.  In  later 
cases  there  is  much  more  difficulty.  Supposing  the  upper  bulbous  end 
to  be  taken  first,  I  think  that  before  this  is  pared  the  nerve  should  be 
carefully  stretched,*  so  that  dissecting-forceps  or  any  other  means  of 
holding  the  nerve  may  inflict  any  necessary  damage  on  parts  that  wdll 
be  cut  away.  It  is  not  necessary  to  cut  away  the  whole  of  a  bulb  ; 
removing  the  greater  part  will  expose  health}^  nerve  fibres.  Mr.  Bowlby 
{Inj.  and  Dis.  of  Nerves,  p.  165)  advises  that  the  section  of  the  upper 
end  should  be  carried  through  the  uppermost  part  of  the  bulb,  close  to 
the  normal  trunk.  Not  only  will  numerous  young  fibres  be  found  here, 
but,  as  he  points  out,  the  tougher  tissue  of  the  bulb  affords  an  excellent 
hold  for  the  sutures.  With  regard  to  the  lower  end,  Mr.  Bowlby  thinks 
that  all  that  is  needed  is  "  to  cut  away  the  extreme  end,  which,  being 
matted  with  fibrous  tissue  and  compressed  b}^  the  surrounding  scar,  is 
very  likely  to  contain  no  nerve  tubules.  It  is  seldom  necessary  to 
remove  as  much  as  a  quarter  of  an  inch,  and,  however  unhealthy  the 
section  may  look,  no  good  is  ever  to  be  gained  by  a  further  sacrifice."  f 

3.  Passinr/  the  Sutures  and  bringing  the  Nerve  Ends  in  Apjwsiiion. — 
The  suture  should  be  of  properly  prepared  carbolised  silk  or  chromic 
gut.  There  has  been  much  dispute  as  to  whether  they  should  be  passed 
through  the  substance  of  the  nerve  itself  or  only  through  the  sheath. 
Experience  has  shown  that  the  former  practice  is  not  onlj^  harmless  to 
the  nerve,  but  is  the  method  most  generally  applicable.  In  a  few  cases, 
as  in  that  of  a  large  nerve,  where  there  is  but  little  separation,  and 
where  the  damage  is  just  inflicted,  it  may  be  sufficient  to  pass  the 
sutures  through  the  sheath  only.  But  in  the  opposite  class  of  case  the 
sutures  should  be  passed  through  the  nerve  itself,  and  at  a  sufficient 
distance  from  the  ends — viz.,  at  least  a  quarter  of  an  inch — otherwise, 
they  will  cut  out  when  they   are  tightened.      Where  there  is  much 


*  An  Esmarch's  bandage,  if  applied,  will  be  found  in  the  way  now,  interfering,  as 
it  usually  must,  with  the  stretching  of  the  nerve. 

f  As  the  whole  length  of  the  lower  end  is  in  the  same  condition  of  degeneration 
throughout,  manifestly  no  good  can  be  done  by  cutting  off  successive  sections  in  the 
hope  that  the  cut  surface  may  look  more  healthy  than  that  which  is  seen  in  the  first 
section  (Bowlby). 


NERVE  SUTURE. 


/J/ 


separation,  several  sutures  should  be  passed  through  part  of  the  depth  . 
of  the  nerve,  one  suture  thus  taking  off  some  of  the  tension  from  its 
fellows.  Another  method  is  to  pass  one  suture  completely  through  the 
nerve  trunk  at  least  a  quarter  of  an  inch  from  each  cut  end.  When  the 
sutures  in  the  nerve  itself  have  been  tied,  two  or  three  more  very  fine 
ones  may  be  placed  in  the  sheath,  where  the  nerve  is  large  enough.* 

In  cases  of  much  separation,  before  anj^  sutiires  are  passed,  and  again 
before  they  are  tied,  the  parts  should  be  as  much  relaxed  as  possible, 
and  the  upper  end  brought  down  by  pressing  down  the  soft  parts. 
Stretching  the  nerve  has  been  already  advised  (p.  /^6).-f 

All  hemorrhage  being  scrupulously  arrested,  and  drainage  provided 
by  horsehair  or  a  fine  tube  according  to  the  amount  of  the  disturbance 
of  the  parts,  &c.,the  usual  dressings  are  applied,  and  the  limb  placed  on 
a  well-padded  splint  in  a  position  which  will  best  retain  the  nerve  ends 
in  apposition  with  the  least  discomfort  to  the  patient. 

Amount  of  Nerve  Tissue  which  rnay  he  Successfulbj  Bemoved. — From 
half  an  inch  to  three-quarters  of  an  inch  is  probably  an  average  amount. 

Causes  of  Failure. —  i.  Wide  separation  of  ends.  2.  Atrophy, 
bulbous  enlargement  and  sclerosis  of  nerve  ends,  so  marked  as  to 
require  much  trimming,  and  thus  tending  to  wide  separation.  3.  Un- 
necessarily rough  handling  of  the  nerve  ends.  4.  Suppuration  of  the 
wound. 

Aids  in  DiflB.cult  Cases. —  I.  Previous  stretching  of  the  ends.  2.  Ap- 
proximation of  the  ends  b}'  position  of  the  limb.  3.  Using  several 
sutures,  which  distribute  the  tension  evenly.  4.  The  use  of  ••  stitches 
of  fixation"  (p.  32,  Vol.  I.).  5.  Autoplastic  operation  with  nerve-flaps. 
M.  Letievant  advises  to  make  a  slit  through  the  nerve  with  a  narrow 
bistoury  about  one-fifth  of  an  inch  from  the  end ;  the  knife  being  then 
carried  upwards  for  an  inch  or  an  inch  and  a  half,  is  made  to  cut  to 
one  side  so  as  to  make  a  flap.  The  same  is  then  done  with  the  lower 
end,  and  the  two  flaps,  being  turned  towards  each  other,  are  united  by 
their  raw  surfaces  (Fig.  29,  Vol.  I.).  6.  Gluck  and  Vanlair  advise 
that  the  nerve  ends,  whether  united  or  only  placed  as  closely  as  possible 
in  apposition,  should  be  passed  through  and  left  in  a  decalcified  bone- 
tube,  so  as  to  keep  the  uniting  material  and  granulations  in  a  straight 
line.  7.  ''  Distance  sutm-es,"  i.e.,  the  substitution  of  threads  of  silk  and 
catgut  may  be  tried  (p.  32,  Vol.  I.).  8.  Cheyne  and  Burghard  {Man.  oj 
Surgical  Treatment)  recommend  a  combination  of  the  last  two  plans,  but 
do  not  mention  any  results.  9.  Scar  tissue  may  be  used  as  a  bridge 
between  the  ends.  Thus,  Mr.  Pick  (Lancet,  1892,  vol.  i.  p.  693)  in  a 
case  of  secondaiy  suture  of  the  median  nerve  more  than  two  years  after 
the  injury,  found  lying  beside  the  upper  cut  end  some  organising 
inflammatory  material.  Dissecting  this  from  the  side  of  the  nerve,  and 
leaving  it  still  attaclied  to  the  lower  end  of  the  upper  piece,  he  turned 
it  down,  and  sutured  it  to  the  lower  end  of  the  nerve.  When  the 
patient  was  last  seen  the  function  of  the  nerve  was  in  process  of  restora- 
tion.     10.  Implanting  one  nerve  trunk  upon  another.     Thus,  where  the 

*  To  prevent  the  adhesion  of  the  recently  united  ends  to  neighbouring  parts,  short 
strands  of  catgut  may  be  placed  beneath  them,  but  this  is  not  essential. 

t  In  cases  where,  in  spite  of  aU  precautions,  much  tension  is  evidently  left  on  the 
sutures,  it  might  be  well  to  make  use  of  "stitches  of  tixation,"  as  in  tendon  suture 
(p.  32,  Vol.  I.). 

VOL.  II.  47 


yT,S  OPEEATTONS  ON  THE  LOWEK  EXTREMITY. 

ulnar  is  too  widely  destroyed  to  bring  the  ends  together,  the  distal  end 
frayed  out,  has  been  stitched  to  the  median,  the  sheath  and  superficial 
fibres  of  this  having  been  first  removed.  The  success  seems  to  have 
been  slight  and  partial.  Dr.  R.  Harvey  Eeed,  of  Cohimbus,  Ohio, 
publishes  a  case  successfully  treated  after  the  following  method,  Avhich 
he  credits  to  Dr.  W.  I.  Galbraith.  of  Omaha,  Nebraska.  This  is 
intended  to  meet  those  cases  where  the  gap  between  the  central  and 
peripheral  ends  is  so  great  that  it  cannot  be  met  by  suture,  or  bridging 
across  by  catgut,  or  tunnelled  over  by  a  tube  of  decalcified  bone.  Dr. 
Galbraith  has  shown  by  a  case  that,  under  the  above  circumstances,  if 
the  injured  nerve  have  another  parallel  with  it,  the  central  end  of  the 
injured  one  can  be  implanted  into  a  parallel  nerve  at  a  certain  point, 
and  that  two  or  three  inches  lower  down  the  peripheral  end  can  be 
implanted  into  the  same  nerve.  1 1 .  Perhaps  the  use  of  zigzag  incisions 
made  in  the  upper  end  (Fig.  25,  Vol.  I.).  12.  Making  use  of  nerve- 
grafts.  Gluck  has  resected  an  inch  and  half  of  the  great  sciatic  in 
chickens,  and  replaced  it  by  a  bit  of  a  rabbit's  sciatic  sutured  in.  The 
birds  walked  afterwards  as  well  as  those  treated  by  direct  suture. 

The  following  is,  I  believe,  the  first  case  of  nerve-grafting  in  this 
countr}^.  Mr.  Mayo  Robson  (Clin.  Soc.  Trans.,  vol.  xxii.  p.  120)  after 
the  removal  of  a  growth  from  the  median  nerve,  leaving  a  gap  of  two 
inches  and  a  half  between  the  ends,  successful!}'  made  use  of  a  corre- 
sponding bit  of  the  posterior  tibial  nerve  from  a  limb  which  was 
amputated  in  the  adjoining  theatre.*  The  following  conditions  are 
rightly  given  as  essential :  First,  the  entire  absence  of  tension  ;  two 
inches  and  a  half  of  nerve  being  employed  to  fill  an  interval  of  two  inches 
and  a  quarter.  Secondh',  great  care  was  observed  in  handling  the  nerve 
to  be  transplanted.  Thirdly,  the  transplanted  posterior  tiliial  nerve  was 
transferred  immediately  as  living  tissue  into  its  new  bed.  Fourthly,  on\j 
one  fine  catgut  suture  was  employed  at  each  end  to  fix  the  nerve.  The 
same  surgeon  successfully  used  the  spinal  cord  of  a  rabbit  as  a  graft  in 
the  median  nerve  of  a  man  (Bi'it.  Med.  Journ.,  Oct.  31,  1896,  p.  13 12). 

In  a  very  instructive  paper  by  Mr.  Damer  Harrison,  of  Liverpool 
(Clin.  Soc.  Trans.,  vol.  xxv.  p.  166),  some  nine  other  cases  of  nerve- 
grafting  are  given.  The  nerves  used  were  the  sciatic  of  recently  killed 
rabbits  or  kittens,  and  the  median  from  a  human  arm.  Of  the  ten  cases, 
three  are  stated  to  have  been  perfectly  successful,  six  partially  successful, 
and  only  one  a  failure. 

Mr.  Heath  made  use  of  nerve-grafting,  replacing  the  gap  in  the  ulnar 
by  a  portion  of  posterior  tibial  nerve  (Lancet,  1893,  vol.  i.  p.  1 195).  A 
fibro-sarcoma  had  been  removed  from  the  ulnar  nerve  on  the  inner  side 
of  the  right  arm,  but  it  had  been  found  impossible  to  bring  the  ends  of 
the  nerve  together,  as  a  gap  of  two  inches  existed  between  them.  Four 
days  after  the  first  operation  the  wound,  which  was  healing  well,  was 
reopened,  and  enlarged  at  either  end.  Tlie  ends  of  the  ulnar  were 
found,  and  about  one-eighth  of  an  inch  cut  off*  from  each  end.  Then 
two  and  a  half  inches  of  the  posterior  tibial  nerve  from  a  limb  which  had 
just  been  amputated  by  Mr.  Beck  for  sarcoma  of  the  lower  end  of  the 
femur  were  grafted  into  the  gap  in  the  ulnar  nerve.  The  graft  was 
retained  in  position  b}"  two  fine  silk  sutures  at  either  end.     About  twenty 

*  In  its  brief  transit  the  nerve  vvas  placed  in  a  solution  of  carbolic  acid  (i  in  40). 


XERVE  STllETCHING.  739 

minutes  elapsed  from  the  time  at  which  the  limb  from  which  tlie  nerve 
was  taken  was  severed  from  the  body  and  the  time  when  the  junction  of 
the  piece  of  nerve  Avith  the  ulnar  nerve  was  comi)leted.  The  wound 
healed  by  first  intention,  but  fourteen  months  later  there  was  no 
restoration  of  function  in  the  nerve. 

Mr.  M.  Moullin,  in  a  case  of  old  injury  to  the  musculo-spiral  nerve, 
grafted  in  about  two  inches  of  the  great  sciatic  of  a  rabbit,  but  without 
success. 

The  graft  does  not  remain  as  nerve  tissue,  but  merel}'  acts  as  a  con- 
ducting material  for  the  growth  of  the  ui'w  nerve  fibrils,  in  the  same 
way  as  strands  of  catgut  may  do. 

13.  In  cases  of  injur}' to  the  musculo-spiral  nerve,  where  the  ends  are 
too  far  apart  to  admit  of  their  junction  by  suture,  they  have  been  suc- 
cessfully approxmiated  by  resecting  sufficient  of  the  humerus — IMieeler 
(Lancet,  1894.  vol.  i.  p.  939),  Mann  (ibid.,  1893.  vol.  ii.  p.  59). 

Period  Feqidred.  for  Bepair. — The  following  appears  to  be  a  fact  not 
sufficiently  recognised.  The  period  required  for  union  after  secondary 
nerve  suture  is  very  much  longer  than  is  usually  supposed  to  be  neces- 
sar\\  owing  to  the  peripheral  end  being  degenerated,  the  muscles  atrophied, 
and  the  joints  fixed.  Complete  restoration  of  function  will  often  require 
from  one  to  two  3'ears.  A  patient  who  leaves  his  svirgeon  apparentlv 
but  little  better  for  the  operation  may  return  at  the  end  of  the  above 
time  with  his  limb  practically  restored  to  its  natural  condition.  ^Ir. 
Bowlby  (loc.  siqrra  cit.)  writes :  "If  there  is  one  fact  more  than  another 
which  stands  out  in  the  clinical  histories  of  jDatients  who  have  been  under 
my  own  observation,  it  is  that  after  the  failure  of  union  by  first  inten- 
tion, after  trophic  changes  of  many  kinds,  after  complete  atrophy  and 
degeneration  of  the  paralysed  muscles,  recovery  may  yet  be  complete." 

It  is  the  condition  of  the  muscles  and  joints  which  alone  puts  anything 
like  a  limit  on  the  period  at  which  secondary-  suture  can  be  success- 
fully practised. 

The  longer  the  interval*  between  the  injmy  and  the  suture,  the  more 
perseveringly  must  friction,  electricity,  passive  and  active  movement, 
and  massage  be  made  use  of,  and  the  more  will  patience  be  required  by 
both  patient  and  surgeon. 


NERVE    STRETCHING. 

This  operation,  introduced  into  England  in  1 880.  and  much  used  in 
the  immediately  succeeding  years,  has  fallen  into  abeyance,  the  clinical 
results  having  failed  to  come  up  to  the  expectations  raised  by  the 
operation. 

Indications. — Of  the  following  list  it  is  only  in  the  first  six  that  the 
operation  can  be  considered  justifiable. 

I.  Xeuralgia?. — In  all  cases  where  previous  treatment  has  tailed,  nerve 
stretching  may  be  practised  before  di\-ision  of,  or  removal  of,  part  of  a 
nerve.  The  conditions  justifying  this  in  facial  neuralgia  have  been 
already  given  (p.  317,  Vol.  I.).   As,  however,  the  results  of  neurectomy  for 


*  The  longest  of  these  with  which  I  am  acquainted  is  a  case  of  M.  Tillaux's  in 
which  fourteen  years  had  elapsed  between  the  injury  to  the  median  and  its  suture. 


740  OPERATIONS  ON  THE  LOWER  EXTREMITY. 

facial  neuralgia  are  far  superior  to  those  of  nerve  stretching,  the  latter 
is  only  to  be  recommended  on  the  ground  that,  owing  to  the  inveteracy 
of  the  disease,  recurrence  is  only  too  probable  even  after  neurectom}', 
and  thus  a  previous  nerve  stretching  may  give  a  further  period  of  relief. 
2.  Sciatica. — Nerve  stretching  is  especially  indicated  here  in  cases  due 
to  rheumatic  inflammation  of  the  nerve  from  exposure  to  cold  and  wet. 
Dr.  J.  P.  Bramwell  has  published  (i?vif.  Med.  Journ.,  June  19,  1880)  five 
cases  of  this  kind,  in  which  much  benefit  followed  stretching  the  great 
sciatic.  The  more  definite  is  the  sensation  of  adhesions  broken  down  at 
the  time  of  the  operation,  the  better  is  the  prognosis.  3.  Locomotor 
ataxy. — One  or  both  great  sciatics  have  been  stretched  wdth  a  view  of 
improving  the  lightning  pains,  the  involuntary  jerkings  of  the  lower 
limbs,  and  the  gait.*  While  improvement  for  a  varying  period  may 
always  be  expected  as  far  as  the  first  two  are  concerned,  the  prospect 
of  improving  the  ataxy  is  verj^  doubtful.  Furthermore,  the  slow  healing 
of  the  wound  in  these  cases  must  be  borne  in  mind.  4.  Spasmodic  con- 
tractions of  voluntary  muscles. — Here  the  operation  seems  to  have  been 
followed  by  success,  temporary  at  least,  in  a  very  large  number  of  cases. 
Where  the  spasmodic  affection  is  of  traumatic  origin — e.;/.,  where  a  limb, 
after  a  contusion,  is  at  the  same  time  contracted  and  the  seat  of  spas- 
modic movements — stretching  of  the  nerves  concerned  maj'  be  absolutely 
curative.  Quite  another  class  of  case — viz.,  stretching  the  facial  for  tic 
convulsif — has  been  considered  at  p.  329,  Yol.  I.  5.  Reflex  epilepsy. — 
Prof.  Horsley  (Did.  of  Surg.,  vol.  ii.  p.  61)  states  that,  in  those  cases  of 
epilepsy  w^here  the  attack  is  preceded  by  violent  pains  localised  distinctly 
to  different  nerves,  xevy  marked  relief  (amounting  to  cure  in  several 
instances)  has  been  obtained  hj  stretching  the  nerve  trunks  thus  indi- 
cated. 6.  Ansesthesia  of  leprosy. — Lawrie,  of  Lahore,  seems  to  have 
met  with  striking  success,  the  fifty  cases  published  being  all  successful. 
The  late  Dr.  B.  Rake  (Brit.  Med.  Journ.,  1890,  vol.  ii.  p.  953)  advised 
repeated  stretching  of  the  great  sciatic  as  preferable  to  amputation  for 
the  painful  perforating  ulcer  of  leprosy.  7.  Infantile  paralysis. — Prof. 
Horsley  (loc.  supra  cit.)  states  that  in  1861  Dr.  Bastian  had  the  great 
sciatic  nerve  stretched  to  improve  the  nutrition  in  a  limb  the  seat  of  the 
above  disease.  The  effect  was  to  markedly  increase  the  temperature  and 
colour  of  the  part,  and  apparently  impro\'e  the  state  of  the  tissues. 
The  result,  however,  does  not  seem  to  have  been  such  as  to  find  imitators. 

Operation. — The  following  remarks  refer  to  the  great  sciatic  only, 
the  nerve  which  has  been  most  frequently  stretched. 

The  parts  being  cleansed,  an  incision  about  foiir  inches  long  is  made 
over  the  nerve  in  the  centre  of  the  back  of  the  thigh,  connnencing  about 
an  inch  and  a  half  below  the  lower  border  of  the  glutteus  maximus. 
The  interval  between  the  hamstrings  being  hit  off",  retractors  are 
inserted,  and  the  nerve  found  a  little  to  the  inner  side  of  the  biceps. 
The  fatty  tissue  around  it  is  then  carefully  incised  till  the  white 
epineurium  itself  of  the  nerve  is  exposed.  The  nerve,  being  most 
entirely   separated  from  adjacent   parts,  is  now  stretched.     The  force 

*  In  a  case  of  Dr.  Bastian's  {Brit.  Med.  Journ.,  July  2,  1881),  the  patient,  in  an 
advanced  stage  of  ataxy,  experienced  so  much  relief  from  the  stretching  of  one 
.great  sciatic,  that  he  asked  for  an  operation  on  the  other  side.  An  interesting  paper 
by  Dr.  Cavafy,  with  nineteen  cases  collected  from  different  sources,  ■will  be  found  in 
the  Brit.  Med.  .Tonrn.,  1881.  pp.  928.  973. 


NERVE  STIIETCIIING.  741 

with  which  tliis  is  accomplished  must  vary  somewhat  with  different 
cases.  Thus,  in  sciatica,  the  index  finger*  being  hooked  under  the 
nerve,  this  should  be  raised  well  out  of  its  bed  in  the  hope  of  adhesions 
being  feit  to  give  way  both  at  the  part  stretched  and  at  a  distance  also. 

In  the  case  of  locomotor  ataxy  the  same  amount  of  stretching — viz., 
hooking  up  the  nerve  some  two  inches  above  the  level  of  the  skin,  and 
some  four  or  five  above  its  bed,  this  being  repeated  twice  in  a  centi'i- 
fugal  and  centripetal  direction — has  been  followed  bj^  satisfactory 
results.  In  other  cases  the  pull  has  been  more  forcible,  care  being 
taken  to  lift  the  limb  off  the  table  several  times.  In  any  case  the  pull 
must  be  without  jerks,  steady  and  continuous,  and  kept  up  for  some 
three  minutes.  Mr.  Marshall  (loc.  supra  cif.)  thought  that  a  force  equal 
to  thirty  or  forty  pounds  should  be  the  limit  for  the  sciatic.  He  thus 
gave  an  idea  of  the  above  force  :  "  If  I  first  pull  as  hard  as  I  imagine 
I  should  do  upon  a  living  sciatic  nerve  during  an  operation,  I  find 
that  the  force  employed  is  about  equal  to  twenty  pounds  ;  but  if  I  pull 
very  hard,  it  is  increased  to  thirty  pounds,  and  that,  I  believe,  is  as 
hard  as  a  surgeon  could  well  pull  when  holding  a  soft  nerve  between 
his  finger  and  thumb."  The  direction  of  the  pull,  whether  downwards 
from  the  trunk  or  upwards  from  the  limb,  has  been  a  good  deal 
disputed.  Mr.  Marshall  (Bradshaice  Lecture,  p.  28)  thought  that  in 
neuralgia  the  stretching  should  be  performed  both  ways.  In  ataxy  it 
is  essential  to  stretch  down  from  the  body. 

The  nerve,  being  found  to  be  loose  and  elongated,  is  replaced  in  its 
bed,  any  bleeding  points  are  attended  to,  drainage  provided,  and  the 
wound  carefully  closed.  Antiseptic  precautions  must  be  made  use  of 
throughout,  and  the  limb  kept  quiet  with  a  splint  or  sand-bags.  The 
tardy  healing  of  the  wound  in  cases  of  atax}^  has  been  already 
alluded  to. 

In  cases  of  stretching  for  sciatica,  gentle  movements  of  the  limb 
shoiild  be  begun  as  soon  as  possible  to  prevent  the  re-formation  of 
adhesions. 

*  111  the  case  of  smaller  nerves  a  blunt  hook  would  be  employed. 


PART   YI. 

OPERATIONS   ON   THE   VERTEBRAL   COLUMN. 


SPINA  BIFIDA.  —  LAMINECTOMY.  —  RACHIOTOMY.  —  PAR- 
TIAL RESECTION  OF  THE  VERTEBRA. — TAPPING  THE 
SPINAL   THECA. 

SPINA    BIFIDA. 

Indications. — All  operative  treatment  should,  if  possible,  be  postponed 
luitil  the  child  is  two  years  of  age  or  older.  The  operation  is  then  borne 
far  better,  as  is  shown  by  published  results.  Where,  in  younger  children, 
rapid  increase  in  the  size  of  the  tumour  is,  however,  taking  place,  and 
leakage  is  threatening  or  has  actually  occurred,  the  methods  of  injection 
or  tapping  may  be  resorted  to  as  palliative  measures,  although  the 
results,  with  few  exceptions,  will  be  disappointing.  Briefl}^,  the 
smaller  the  tumour ;  the  less  the  evidence  of  involvement  of  the  spinal 
cords  or  nerves  ;*  the  more  the  skin  over  the  tumour  approaches  to 
normal  ;  the  less  the  tumour  shows  signs  of  increase  in  size  ;  and  the 
older  the  child — the  greater  are  the  chances  of  cure.  The  greatest 
possible  importance,  therefore,  attaches  to  the  question  of  careful 
selection  of  cases  to  be  submitted  to  operative  interference. 

Operations. —  i.  Injection  with  Morton's  Fluid.  2.  Simple  Tap- 
ping and  Drainage.      3.  Excision. 

All  the  above  are  liable  to  be  followed  b}^  septic  meningitis  aided  by 
the  constant  soaking  away  of  cerebro-spinal  fluid,  especially  where  the 
coverings  of  the  sac  are  thin  and  unhealthy. 

I.  Injection  with  Morton's  Fluid. — The  Clinical  Society's  Com- 
mittee {Trans.,  vol.  xviii.)  collected  yi  cases  treated  by  this  method. 
Of  these,  35  recovered,  27  died,  4  were  relieved,  and  5  unrelieved.  In 
a  letter  to  the  Committee  (dated  May  1 1,  1885),  Dr.  Morton  was  able  to 
refer  to  50  cases  thus  treated.     Of  these,  41  appear  to  have  been  suc- 

*  Points  which  make  it  probable  that  nerve  trunks  or  the  cord,  or  both,  are 
present  in  the  sac,  are  paralysis  of  the  sphincters  or  lower  extremities,  a  large  sessile 
tumour  with  a  broad  base,  and  the  appearance  of  cord-like  bands  when  the  sac  is  thin 
enough  to  transmit  light. 


SPINA  IJIFIJJA.  743 

cessful,  and  9  iinsuccessful.  But  it  is  obvious  that  these  statistics  are 
largeh-  unreliable.  It  is  not  iinfair  to  say  that  nearly  every  successful 
ease  has  been  at  once  reported,  while  scores  of  unsiiccessful  ones  have 
never  been  heard  of.  Owing  to  the  large  number  of  successes  which 
attended  the  use  of  this  method,  it  is  the  only  one  which  was  recom- 
mended by  the  Committee  of  the  Clinical  Society.  It  is  impossible  to 
point  out  too  strongly  to  my  younger  readers  that  it  is  only  by  a 
judicious  selection  of  cases  that  any  success  can  be  expected. 

The  sac  being  cleansed,  a  syringe  which  will  hold  about  two  di-achms 
of  the  iodo-glycerine  solution*  is  chosen,  and  a  fine  trocar.  The  calibre 
of  this  must  not  be  too  fine  for  the  thick  fluid  which  has  to  pass  through 
it.  The  puncture  into  the  swelling  should  be  made  well  at  one  side, 
obliquely  through  healthy  skin,  and  not  through  the  membranous  sac- 
wall,  the  objects  being  to  avoid  wounding  the  cord  or  nerves,  and  also 
to  diminish  the  risk  of  leakage  of  cerebro-spinal  fluid.  Unless  the 
sac  is  ver}'  large  it  is  probably  better  not  to  draw  off"  much,  if  any,  of 
the  fluid  from  the  sac  on  the  first  occasion.  The  position  of  the  child 
during  the  injection  has  been  a  good  deal  dwelt  upon,  most  recom- 
mending that  it  should  be  upon  its  back.  The  Clinical  Society's  Com- 
mittee advise  that  the  child  should  be  upon  its  side.  Aboiit  a  drachm 
of  the  fluid  should  be  injected.  EvSry  care  must  be  taken  to  prevent 
any  continued  escape  of  the  cerebro-spinal  fluid,  now  and  later,  it 
being  clearly  understood  that  any  such  leakage,  which  is  niost  difficult 
to  prevent,  W'ill  lead  to  septic  meningitis  and  death.  When  the  needle 
is  withdrawn  the  puncture  should  be  pressed  around  it,  and  immediately 
painted  with  collodion  and  iodoform,  a  dressing  of  dry  gauze  being  also 
secured  with  collodion.  I  prefer  to  give  a  little  chloroform  to  prevent 
any  crying  and  straining  at  the  time.  The  child  should  be  kept  as 
cpiiet  as  possible  afterwards,  on  its  side,  and  an  assistant  should  make 
sure,  for  the  first  hour  at  least,  that  no  leaking  is  going  on.  Shrinking 
of  the  cj'st,  continuing  steadily,  shows  that  all  is  well.  If  the  injection 
fail  altogether,  or  onl}^  cause  partial  obliteration  of  the  sac,  it  should  be 
repeated  at  intervals  of  a  week  or  ten  days. 

2.  Simple  Tapping  and.  Drainage. — This  consists  of  either  tapping 
with  a  very  line  trocai-  and  carefully  sealing  the  opening,  or  inserting  a 
single  piece  of  horsehair  as  a  di-ain.  The  use  of  the  horsehair  drain  is 
not  to  be  recommended,  as  the  leakage  cannot  be  kept  sweet.  The 
method  is  only  palliative. 

3.  Excision  of  the  Sac.t — This  is  the  method  which  I  recommend, 
and  which,  in  spite  of  certain  grave  dangers,  promotes,  1  think,  the 
best  results  in  carefully  selected  cases.  The  dangers  are.  of  course,  the 
suddenness  with  which  the  fluid  may  escape,  with  grave  resulting 
changes  in  the  hj^drostatic  pressure  and  circulation  in  the  cerebro- 
spinal system,  shock  from  interference  with  important  nerve  filaments, 
and  meningitis  set  up  as  the  result  of  subsequent  leakage. 

The  too  rapid  escape  of  fluid  can  be  prevented  in  great  measure  by 


*  The  fluid  is  iodine,  gr.  x  ;  iodide  of  potassium,  5j ;  glycerine,  5j. 

t  The  Clinical  Society's  Committee  collected  23  cases  treated  by  excision  of  the 
sac.  Of  these,  16  recovered,  7  died.  They  point  out  that  no  mention  of  the  contents 
of  the  sac  is  made  in  6  cases;  that  nerves  were  certainly  absent  in  16  cases;  and 
that  in  i,  which  was  fatal,  they  were  certainly  present  (Trang.,  vol.  xviii.  p.  380). 


744       OPERATIONS  OX  THE  VEKTEBEAL  COLEMX'. 

preliminaiy  tapping  and  attention  to  the  position  of  the  patient.  The 
presence  of  nerves  in  the  sac  is  a  graver  matter,  but  with  a  larger 
experience  surgeons  will,  I  believe,  find  that  the  nerves  and  the  closely 
contiguous  sac  can  be  safely  returned  within  the  canal,  and,  when  re- 
placed, covered  over.  On  this  point  Mr.  M.  Robson  (^Ann.  of  Surg.  1895, 
vol.  ii.)  writes:  '-Even  when  nerve  cords  are  involved  in  the  sac,  an 
aseptic  plastic  operation  can  not  only  be  safely  performed,  but  will 
actually  do  less  damage  to  these  important  structures  than  the  in- 
jection of  an  irritant,  which,  if  it  does  not  lead  to  rapid  death  b}' 
shock  or  convulsions,  or  to  a  general  irritation  of  the  nerve  centres 
rapidly  tending  to  hydrocephalus,  is  followed  by  a  shrinking  and 
atrophy  of  the  sac  and  its  contents,  whether  nerves  or  spinal  cords." 

Operation. — The  parts  having  been  cleansed  and  arrangements  made 
for  keejDing  the  head  low  j^i'ior  to  and  during  the  opening  of  the  sac, 
elliptical  incisions*  are  made  through  the  skin  on  either  side  on  and 
sufficiently  far  from  the  base  to  ensure  if  possible  (a)  sound  skin  and 
(/S)  sufficient  skin  to  meet  in  the  middle  line  after  partial  excision  of 
the  sac  and  removal  of  the  fluid.  The  skin  is  then  dissected  back  on 
each  side  with  great  care  so  as  to  avoid,  if  possible,  punctures  of  the 
membranes,  until  the  lamina?  are  reached.  It  may  now  be  found  that 
the  tumour  is  clearly  a  meningocEele  being  attached  by  a  pedicle,  which 
ma}'  be  quite  slender.  In  such  a  case  the  tumour  ma}'  be  forthwith 
removed  after  ligature  of  the  pedicle.  This  was  done  with  success  in 
two  cases  in  adult  women  b}'  Mr.  Glutton  (Ann.  of  Surg.  vol.  i.,  1898, 
p.  253).     In  both  cases  the  tumour  was  situated  in  the  sacral  region. 

If  there  is  no  pedicle  the  sac  is  now  careful!}'  opened,  at  first  with  a 
trocar  so  that  the  fluid  is  slo^vly  withdrawn,  and  the  effects  on  the 
cerebral  centres  noted.  The  oj)ening  is  then  enlarged,  and  the  interior 
carefall}'  examined.  If  no  nerve  structures  are  present,  the  redundant 
sac  is  then  cut  awa}'  with  blunt-pointed  scissors,  and  the  edges  brought 
together  with  a  continuous  suture  of  catgut  or,  better,  kangaroo  tendon. 
>So  far  the  operation  has  been  simple  and  straightforward.  We  must 
now  consider  more  difficult  cases.  Where  the  coverings  are  in  great 
part  thin  and  translucent,  even  when  this  condition  extends  to  the 
margin  of  the  swelling,  if  the  coverings  can  be  rendered  aseptic  they 
may  be  partly  utilised  to  forin  the  meningeal  flaps,  the  adjoining- 
skin  being  undermined  and  made  to  slide  over  the  new  meninges 
(Mayo  Robson). 

When  on  opening  the  sac  nerve  structures  are  seen  within,  that  part 
of  their  course  which  lies  in  the  sac  must  be  carefullv  detached  Avitli 
blunt-pointed  instruments,  until  the}'  can  be  gently  pushed  through  the 
opening  that  communicates  with  the  spinal  canal.  In  more  difficult 
cases,  incisions  must  be  made  with  blunt-pointed  scissors  between 
portions  of  nervous  structures,  in  order  to  set  them  free,  or  they  must 
be  returned  with  a  part  of  the  sac  en  masse.  In  cases  where  the 
presence  of  nerve  structures  difficult  to  detach  is  marked,  the  safest 


*  A  precaution  of  Mr.  Eo1jsou"»  (_Clin.  >'^'oc.  'Trans.,  vol.  xviii.  p.  211)  should  be 
followed  here.  The  skin  and  meningeal  flaps  should  be  so  cut  that  their  lines  of 
union,  when  sutures  are  applied,  are  not  opposite.  Thus,  the  flaps  should  be  cut  of 
unequal  width,  so  as  to  bring,  r.-y.,  the  wider  skin  flap  on  the  left  side,  and  the  wider 
meningeal  one  on  the  right. 


SPINA    IMllDA.  745 

plan  will  be  the  last.  Having-  opened  and  exaniiiu'd  the  j-ac,  the 
surgeon  cuts  away  any  superfluous  part  that  is  safe,  then  detaches  the 
remainder  and  returns  it  with  the  nerves  which  run  in  it.  through  the 
opening,  into  the  canal.*  It  is  greatly  to  be  desired  tiiat  surgeons 
should  specify  what  nervous  structures  were  present,  and  how  they 
were  dealt  with.     As  a  rule  this  has  been  most  im])ertectly  done. 

The  nerve  structures  having  been  returned,  the  flaps  of  meninges  and 
skin  are  sutured  separately  and  not  in  one  line  (]).  744).  In  some 
cases  periosteal  grafts  or  bones  from  freshly  killed  aninials  have 
been  introduced  with  varj^ng  success. t  Considering  the  tender  age 
and  feeble  powers  of  these  patients — infants,  as  a  rule — it  is  certainly  not 
worth  while  to  prolong  an  operation,  amesthetic.  &c..  for  this  purpose. 
If,  however,  the  patient  is  not  an  infant  and  the  condition  is  good,  and 
moreover  if  the  gap  in  the  sjiine  is  a  large  one,  an  attempt  should  be 
made  to  protect  this  b}-  means  of  flaps  of  aponeurosis  and  muscle 
derived  from  the  erector  spinoe.  Either  one  large  flap  may  be  raised 
and  swung  across  so  that  the  line  of  sutures  is  at  the  side,  or  two  flaps 
may  be  used  and  united  in  such  a  manner  that  the  line  of  sutures  is  not 
immediately  beneath  the  skin  sutures.  The  very  lowest  part  of  the 
meningeal  and  skin  flaps  ma}'  be  left  unsutured,  but  no  drainage  will  lie 
needed,  and  leakage  is  greatly  to  be  deprecated.  Iodoform  gauze  wnnig 
out  of  carbolic  acid  lotion  (1-20)  having  been  placed  on  the  wound,  a 
suflScient  thickness  of  salicylic  wool  is  then  applied,  and  bandaged  with 
firm  and  even  pressure.  I'or  the  first  few  days  the  head  should  be  kept 
low  and  the  spine  raised  so  as  to  prevent  the  tendency  to  leakage  of 
cerebro-spinal  fluid.  A  shield  of  silver,  vulcanite,  or  thin  sheet-lead 
should  be  worn  later  until  the  parts  have  thoroughly  consolidated. 

Causes  of  Failure  after  the  Radical  Cure  of  Spina  Bifida. — 
I.  Leakage  and  septic  meningitis.  2.  Convulsions  and  rapid  death. 
Mr.  Glutton,  who  brought  a  successful  case  of  Dr.  Morton's  treatment 
before  the  Clinical  Society  (Tran.^.,  vol.  xvi.  p.  34).  mentioned  another  in 
which  this  treatment  was  immediately  followed  by  fatal  convulsions. 
The  same  proved  fatal  in  about  ten  hours  in  a  case  under  my  care.  Mr. 
Bennett,  during  the  same  discussion,  mentioned  a  case  in  which,  owing 
to  the  child  being  indisposed  at  the  time,  he  declined  to  operate.  On 
its  way  home  the  child  died  of  convulsions.  He  remarked  that  if  he  had 
used  the  injection,  this  would  have  been  credited  with  the  convulsions. 
3.  Paraplegia.  This  setting  in  after  injection  may  be  temporary  or 
])ermanent.  4.  Hydrocephalus.  This  also  may  make  its  appearance 
after  the  injection  with  iodo-glycerine  or  excision,  as  happened  in 
a  case  of  my  own  three  days  after  the  latter  operation.  The  nerves 
here  were  few  and  small  and  easily  detached  with  the  adjacent  sac 
into  the  canal.  5.  After  tapping  or  injection  the  swelling  may 
progress  unaltered. 


*  In  those  cases  where  there  is  a  distincl  pedunek'.  this,  if  hulluw.  must  first  be 
opened  to  inspect  its  interior.  If  it  contain  1.0  structures  of  importance  it  is 
secured  by  running  it  round  with  a  kangaroo-tendon  ligature,  and  the  sac  beyond 
cut  away. 

t  Dr.  E.  T.  Hayes,  of  Hochejter  (X.  Y.),  introduced  twenty  grafts  of  periosteum  from 
a  freshly  killed  rabbit.  Three  months  later  the  case  was  reported  satisfactory,  with 
a  firm,  hard,  resistant  covering.     (^V<y/.  Becord,  June  16,  18S3). 


746  OPICRATIOXS  OX  THE   \^EKTE]3RAL   COLUMN. 

LAMINECTOMY.— RACHIOTOMY.—  PARTIAL    RESECTION 
OF    THE    VERTEBRJE. ' 

This  rare  operation,  which  has  of  late  been  revived,  must  be  referred 
to  here  under  the  following  indications  :  A.  Cases  of  injury,  i.e.,  Frac- 
tures and  Dislocation.  B.  Penetrating  wound  of  the  canal.  C.  Cases  of 
inflaonmatory  disease — e.(j.,  Pott's  curvature.     D.   Cases  of  neiv  ffrowth. 

A.  Cases  of  Ltjury. — Here  the  operation  has  been  suggested  by  the 
analogous  one  performed  on  the  skull,  and  tlie  large  amount  of  success 
which  has  followed  it.  But  the  analogy  is,  for  several  reasons,  a  decep- 
tive one.  Thus,  owing  to  the  small  size  of  the  cord,  an  injury  which 
would  only  damage  the  brain  slightly,  almost  inevitably  destroys  the 
structure  of  the  cord  throughout  its  thickness.  Again,  it  must  be 
remembered  that  a  fragment  of  bone  often  inflicts  injury  upon  the  cord 
instantaneously,  and  that  in  a  moment  irremediablef  damage  may  be 
done,  though  all  deformity  may  be  removed  by  raising  and  straighten- 
ing the  patient,  and  by  the  elasticity  of  the  bones  and  the  contraction 
of  the  muscles.  Further,  the  cord  may  be  most  severely  damaged, 
though  its  theca  shows  no  sign  of  injury. 

Again,  when  the  surgeon  trephines  the  skull,  he  not  only  hopes 
that  the  damage  is  slight  and  of  a  removable  nature,  but  he  also 
believes  that  the  onl)^  damage  to  the  bones  is  that  which  lies  close  to  his 
trephine  and  finger.  But  in  the  case  of  the  spine  we  are  faced  by  this 
dilemma :  If  the  fracture  has  been  from  direct  violence,  and  the  spinous 
processes  and  laminge  have  been  driven  in,  it  is  only  too  probable  that 
when  these  are  elevated  the  spinal  cord,  so  limited  in  size,  will  be  found 
too  much  damaged  to  profit  by  the  operation.  On  the  other  hand,  if 
the  fracture  has  been  caused  b}^  indirect  violence,  it  is  almost  certain 
that  the  bodies  of  one  or  more  vertebrae  will  have  been  crushed  down, 
and  a  portion  shot  back  into  the  canal.:!:  In  this  case  the  !.fragment 
which  has  inflicted  the  injurj^,  and  which  is  keeping  up  the  irritation, 
will  be  in  front  of  the  cord  and  out  of  reach,  even  if  the  cord  were  in  a 
condition  to  be  much  benefited  by  its  removal.  A  surgeon  trephining 
the  spine  under  these  conditions  would  be  like  one  who  trephined  the 
skull  in  order  to  remove  depressed  fragments  of  the  vertex,  when  all 
the  time  a  portion  of  the  base  of  the  skull  was  lying  jammed  into  the 
under  surface  of  the  brain. 

But  it  is  not  only  in  the  damage,  but  in  the  violence  of  the  fracture 
also  that  no  analogy  lies  between  the  two  cases.     Fracture  of  the  spine 

*  Of  these  names  the  third  is  the  only  one  which  is  correct  and  sufBcient.  It  is, 
however,  too  long  and  cumbrous  for  general  use  in  these  days  of  hurry.  Rachiotomy, 
which  we  owe  to  Mr.  Davies-Colley,  is  very  good  as  far  as  it  goes,  but  iusuiBcient.  In 
this  operation  a  good  deal  more  is  done  to  the  vertebras  than  merely  cutting  into 
them.  Laminectomy,  like  appendicectomy,  is  objectionable  from  its  hybrid  deriva- 
tion, but  as,  like  the  above  term,  it  is  explicit,  convenient,  and  already  in  general 
use,  it  will  be  used  here. 

f  Hence  accounting  for  the  very  grave  fatality  of  fractures  of  the  spine,  a  fact  held 
by  some  to  justify  trephining.  The  above  account  is  taken  from  my  article  on 
"  Injuries  of  the  Back,"  t^yst.  of  Sunj.,  vol.  i.  p.  673. 

X  This  is  a  very  common  condition,  judging  from  museum  specimens.  It  is  well 
illustrated  by  Figs.  93  and  94  in  my  article  to  which  I  have  alluded  above. 


PAETIAL  r.ESECTIOX  OF  THE   VEKTEBK.E.  747 

is  usually  due  to  indirect  violence,  as  when  the  neck  is  broken  by  a  fall 
on  the  head,  or  when  the  lower  dorsal  spine  is  fractured  by  a  fall  of  a 
sack  upon  the  shoulders.  Even  when  the  fracture  is  due  to  direct 
violence,  it  is  of  an  entirely  different  nature  to  that  for  which  the 
surgeon  hopes  to  trephine  successfully  in  the  skull,  and  one  far  more 
likely  to  produce  extensive  and  crushing  damage — e.ij.,  the  fall  of  coal 
or  earth,  or  a  fall  from  a  height  upon  a  projecting  body. 

Finally,  permanent  compression  of  the  cord — compression  that  can  be 
removed,  as  can  fragments  of  the  skull — is  a  very  rare  event.*  Even 
where  permanent  compression  is  present  laminectomy  will  do  very 
little.  The  surgeon  may  find  it  possible  to  restore  the  lumen  of  the 
vertebral  canal,  but  the  cord  has  been  crushed  as  well  as  compressed. 
Mischief,  usually  hopeless  mischief,  has  been  done,  for  it  has  been 
proved  by  experiments  and  otherwise  that  a  crushed  cord  is  incapable  of 
regeneration. 

It  remains  t;o  be  shown  that  trephining  the  spine  is  not  only  likely 
to  be  void  of  any  good  results,  but  that  it  also  involves  serious  risks  and 
entails  additional  dangers  of  its  own.  Thus,  the  conversion  of  a  simple 
into  a  compound  fracture,  the  formation  of  a  large,  deep,  and  more  or 
less  ragged  wound,  the  risk  of  subsequent  suppuration  with  free  access 
to  the  sheath  of  the  cord,  the  opening  up  of  cancellous  tissue  with 
its  various  channels  and  exposure  of  these  to  possible  su])puration 
— all  these  have.  I  admit,  been  lessened  by  the  use  of  antiseptic  pre- 
<iautions.  But  the  risk,  though  diminished,  remains ;  the  large  amount 
of  venous  oozing  tending  to  soak  quickly  through  in  this  region  can 
only  be  met  by  frecjuent  dressing.  And  though  it  has  been  shown  that 
in  some  of  these  cases  the  wound  has  healed  cpiickly,  and  though  no 
improvement  has  followed,  the  spinal  column  has  not  been  fatally 
weakened  by  the  removal  of  the  laminag  and  spines,  j'et  the  weakening 
for  a  time  must  be  considerable  ;  and  it  must  be  remembered  that  by 
the  removal  of  these  structures  the  mobility  of  the  fractured  parts  will 
be  miich  increased,  and  when  any  attempt  is  made  to  vary  the  position 
of  the  patient  in  bed,  there  will  be,  for  some  time,  a  risk  of  disturbing 
the  fi^agraents  and  thus  of  inflicting  further  injury  on  the  cord. 

It  will  be  seen  from  the  above  that  my  own  opinion  is  averse  to  any 
surgical  interference  in  cases  of  fractui'ed  spine,  owing  to  the  amount 
of  damage  to  the  cord  being  usually,  from  the  first,  irreparable.  To 
quote  other  writers:  Mr.  Thorburn  (Nwyv/e/*^  of  the  Spinal  Cord,  1889, 
p.  160 :  Brit.  Med.  Journ.,  1 894.  vol.  i.  p.  1 348)  comes  to  the  same 
conclusion,  but  draws  an  important  distinction  between  the  cord  and  its 
nerves.  This  writer  thus  sums  up  the  question  of  operative  inter- 
ference in  fractures  and  dislocations  of  the  spinal  column  (Joe.  siqyra 
Ht.):  ''In  compound  fractures,  operate.  In  fractures  of  the  spinous 
processes  and  lamina^,  with  injury  to  the  cord,  we  also  operate.  In 
simple  fractures  and  dislocations  of  the  bodies  of  the  vertebra\  if  there 
is    a    reasonable  probability  that  the  injury  is   due  to  ha?morrhage,t 

*  J.  Hutchinson,  LotuI.  Uosp.  Rejt. ;  Thorburn,  loc.  infra  cit.  It  will  be  noticed 
that  permanent  compression  is  a  very  different  thing  from  irreparable  injury.  The 
latter  is  present,  only  too  frequently. 

t  Mr.  Thorburn  thinks  that  the  following  would  be  the  most  advisable  steps  in 
these  very  rare  cases  :  A  laminectomy  at  the  seat  of  injury,  and  an  endeavour  to  arrest 


748  OPERATIO>'S  OX  THE  YEiriEBKAL  COLUMN. 

operation  is  advisable,  but  in  all  other  cases  of  this  nature  we  cannot 
hope  to  do  good  save  Avhere  the  injur}'  is  below  the  level  of  the  first 
lumbar  vertebras.  In  such  cases  laminectomy  is  an  eminently  valuable 
surgical  procedure."  Mr.  Thorburn  advocates  surgical  interference 
here  on  the  following  grounds:  (i)  "We  may  here  expect  a  regenera- 
tion of  the  nerve  roots,  the  physiological  evidence  being  strongly  in 
favour  of  such  regeneration,  and  not  against  it,  as  in  the  case  of  the 
cord.  (2)  The  absence  of  spontaneous  recover}^  in  such  cases  in  itself 
indicates  the  presence  of  a  mechanical  obstacle,  such  as  permanent 
compression  by  bone,  blood-clot,  or  cicatrix,  otherwise  we  should  expect 
the  roots  of  the  cauda  ecjuina  to  recover,  as  other  peripheral  nerves 
after  severe  injuries."  Dr.  J.  W.  White  (Ann.  of  Sun/.,  July,  1 889) 
strongly  advocates  surgical  interference  in  fractured  spine,  believing 
that  fracture  of  the  lamiute  and  spinous  processes,  and  therefore 
relievable  pressure  on  the  cord,  Avill  not  be  found  so  rare  as  has  been 
usually  believed.  I  fear  the  weight  of  pathological  evidence  is  all  the 
other  way.  For  my  own  part  I  should  onl}  be  inclined  to  interfere 
where  the  following  conditions  are  present :  A  history  of  a  direct 
injury ;  mobility  and  displacement,  laterally  or  downwards,  of  the 
spinous  process ;  great  local  tenderness ;  the  usual  symptoms  of 
swelling,  &c.  ;  and  pax'aplegia  less  marked  than  usual. 

B.  Penetratinr/  Wounds  of  the  Spinal  Cord. — Mr.  Thorburn  [loc.  supra 
cit.)  shows  that  while  the  percentage  of  recovery  is  good  as  to  life, 
complete  recovery  of  function  is  uncommon,  owing  to  the  little  power 
of  recovery  of  function  after  a  destructive  lesion  of  the  spinal  cord  in 
man,  especially  in  adults.  He  would  also  regard  as  useless  the 
operation  of  suture  of  the  pia  mater  as  proposed  by  Chipault,  and  points 
out  that  it  may  be  harmful  not  only  by  necessitating  manipulation  of 
the  injured  cord,  but  also  by  confining  effused  blood  and  serum,  and 
thus  increasing  the  pressure  upon  those  parts  M-hicli  have  escaped 
section.  With  the  nerve  roots,  on  the  other  hand,  which  are  capable 
of  repair,  operation  and  suture  would  be  quite  justifiable. 

C.  Cases  of  Inflammatory  Disease — e.g.,  Potfs  Curvature.* — Interference 


the  hEemorrhage  and  to  give  exit  to  the  blood  ;  this  procedure  beiug  combined  in  the 
first  instance  with  paracentesis  of  the  meninges  in  the  lumbar  region  after  Quincke's 
method  (vide  infTa~),  and  this  failing,  a  secondary  laminectomy  at  the  lower  part  of 
the  spine. 

*  Eeference  should  be  made,  in  addition  to  the  writings  quoted  above,  to  the 
following:  (i)  In  cases  of  injury,  Macewen,  Brit.  Med.  Joiirn.,  1888,  voL  ii.  p.  308; 
Keetley,  ?■*(■<;?.,  p.  421;  Duncan,  Edin.  Med.  Joiirn.,  1889,  p.  S30;  E.  Hart,  a  case  of 
M.  Pean's,  Brit.  Med.  Jouin.  1889,  vol.  i.  p.  G72  ;  H.  W.  Allingham,  ibid,  p.  83S  ; 
Chipault,  Gaz.  des  H62). ;  Arch.  Gen.  de  Med.,  1890;  Rev.  de  Chir.,  1890,  1891,  and 
1892;  these  caretul  and  elaborate  papers  are  now  embodied  in  Chipault's  work  on  the 
Surgery  of  the  Nervous  System;  Schede  of  Hamburg,  Ann.  of  Siinj.  1892,  vol.  ii.  p.  230; 
Wyeth,  ibid.,  August,  1894;  Biddell,  Med.  and  Surg.  Beporter,  March  30,  1895;  Lejare, 
Gaz.  des  Hit]).,  June  2, 1884  ;  Arnison,  ibid..  May,  1895.  (2)  In  cases  of  Pott's  curvatures, 
Macewen  and  Duncan  Qoe.  supra  cit.')  ;  Wright,  Laneit,  July  14,  1888  ;  W.  A.  Lane,  Brit. 
Med.  Joiirn.,  April  20,  1889  ;  Lancet,  July  5,  1890  ;  Abbe,  New  York  Med.  Jmirn.,  Nov.  24, 
1888  ;  Kraske,  Centr.f.  Chir.,  1890,  Heft  25  ;  Dr.  S.  Lloyd,  of  New  York,  Aim.  <f  &iir<j., 
1892,  vol.  ii.  p.  289 ;  BuUard  and  Burrell,  Trans.  Med.  Ortliop.  Assoc,  vol.  ii.  p.  241. 
Several  of  the  above  cases  have  been  reported  so  soon  after  the  operation  that  their 
value  would  be   much  incicased   by  the  authors  giving  later  details.     (3)  In  cases  of 


PARTIAL  RESECTION  OF  THE    VERTEBR.E.  749 

here  will  be  but  very  rarely  called  for.  For,  on  the  cue  hand,  the 
pathology  of  these  cases  makes  them  much  more  hopeful  than  in  fracture, 
the  paralysis  here  Ijeing  due,  not  to  pressure  of  displaced  vertebrae,  or  to 
irremediable  damage  of  the  cord — e.7.,  mj^elitis,  degeneration — but  to 
the  results  of  a  chronic,  localised,  external  pachymeningitis,  producing 
pressure  by  a  mass  of  scar-like  connective  tissue.  On  the  other  hand, 
we  have  abundant  evidence  that  paralysis,  even  when  of  long  duration, 
has  a  marked  tendency  to  recover}^  if  the  treatment  by  absolute  rest  in 
the  recumbent  position  is  vigorously  enforced,  and  if  potassium  iodide 
is  pushed  in  large  and  frequent  doses,  after  the  American  method.* 

Mr.  Thorburn  {loc.  supra  cit.)  gives  the  following  indications  and 
contra-indications  for  operation.  Indications:  (i)  "  Assuming  the 
prognosis  to  be  thus  favourable,  we  are  never  called  upon  to  perform 
laminectomy  save  under  certain  special  conditions.  It  will  not  be 
argued  that  the  recovery  after  laminectomy  is  more  complete  than  that 
produced  by  Nature,  and  experience  shows  that  relapses  also  are  only 
too  common  after  operation.  The  indications  which  appear  to  me  to 
point  to  the  necessity  for  operations  are  then  as  follows  :  A  steady 
increase  in  syjnptoms  in  spite  of  favourable  conditions  and  treatment. 
The  presence  of  symptoms  which  directly  threaten  life.  Thus,  in  my 
second  case,  the  secondarv  chest  troubles  were  very  grave.f  Intractable 
cystitis  would  fall  into  this  category,  but  it  is  by  no  means  common,  and 
we  can  hardly  agree  with  those  who  hold  that  the  condition  is  in  itself 
incapable  of  spontaneous  recovevj. 

"  The  persistence  of  symptoms  in  spite  of  complete  rest,;):  is  the 
indication  which  has  been  most  commonlj^  adopted,  but,  as  we  have 
already  seen,  such  symptoms  may  persist  for  very  long  periods  and  then 
yield  to  absolute  rest.  It  is,  however,  not  improbable  that,  in  a  few 
cases,  cicatricial  pachymeningitis,  or  rather  peri-pacli}-meningitis,  may 
remain  after  the  original  pressure-lesion  has  ceased  to  act,  and  may 
thus  keep  up  paraplegia  until  the  constricting  tissue  is  removed. 

"  4.  In  posterior  caries  (that  is,  in  caries  of  the  arches  of  the  vertebrae) 
operation  is   clearly  indicated,  as  here  we  can  readily  both  treat  the 


new  growths,  Dr.  Gowers  and  Mr.  Ilorsley's  paper  Qoc.  supra  cit.)  and  the  appended 
table.  See  also  Dr.  .J.  W.  White's  paper  Qoc.  supra  cit.},  and  his  table  of  the  most  obvious 
diagnostic  points,  p.  32;  Starr,  '-Tumour  of  the  Spinal  Cord,"  Amcr.  Joiirn.  Mid.  Sor. 
June,  1895  ;  and  Patnam  and  Collins  Warren  ^Avier.  Jowrn.  of  Med.  Sci.,  Oct.  1899). 

*  In  an  adult  gr.  x-xx  is  given  every  half -hour,  if  possible,  in  a  large  glass  of  milk. 

t  Dr.  Parkin,  of  Hull,  in  a  valuable  paper  (^Brit.  Med.  Journ.,  1S94,  vol.  ii.  p.  700) 
illustrated  by  cases  of  laminectomy  for  spinal  caries,  mentions  a  case  aged  9,  admitted 
for  cervical  caries,  cyanosis  and  bronchitis.  As  the  condition  became  more  critical, 
the  sixth  cervical  spine  was  removed.  The  cord  was  found  compressed  and  bent  by  a 
mass  of  bone  and  fibrous  tissue,  the  remains  of  the  fourth  and  fifth  vertebra;.  When 
the  cord  was  freed,  pulsation  returned.  Very  great  benefit  followed  on  the  operation, 
but  the  child  died  nearly  three  months  after  of  tubercular  meningitis,  thought  to  be 
due  to  a  caseating  gland  found  at  the  necropsy.  No  evidence  of  caseation  or  recent 
caries  was  found  in  the  vertebne. 

X  Readers  with  careful  and  well-balanced  minds  will  not  fail  to  note  on  reading  the 
accounts  of  many  of  these  cases,  published  as  successful  cases  of  laminectomy  for 
spinal  caries,  that  many  of  them  before  being  submitted  to  operation,  had  only  been 
treated  by  rest  for  a  few  days  or  weeks,  "  the  mother  having  full  directions  to  keep  the 
child  in  the  same  horizontal  posture."  In  other  cases,  after  a  brief  period  of  in-patient 
treatment,  the  children  have  been  sent  out  in  Sayre's  jackets  to  attend  as  out-patients. 


750  OPERATIONS  ON  THE  VERTEBRAL   COLUMN. 

paraplegia  and  remove  the  whole  of  the  tuberculous  tissue.  Two  cases 
of  this  nature  are  recorded  by  Abbe  and  by  Chipault  respectively,  and 
both  proved  highly  successful. 

"5.  In  my  fifth  case,  the  existence  of  severe  pain,  which  was  rapidly 
exhausting  the  patient,  was  regarded  as  an  indication  for  surgical 
interference. 

"  6.  Lastly,  children  as  a  rule  yield  better  results  than  do  adults,  so 
that,  other  things  being  equal,  childhood  may  also  be  regarded  as  an 
indication  for  operation. 

"  Contra-indications. — The  presence  of  active  tuberculous  changes  in 
other  organs.  Macewen  holds  that  we  should  not  operate  when  there  is 
pyrexia,  which  is  almost  tantamount  to  saying  that  we  should  not 
operate  in  presence  of  active  tuberculosis.  If,  however,  the  pyrexia 
were  clearly  due  to  cystitis,  then  we  might  regard  it  as  an  indication 
for,  rather  than  against,  interference.  Again,  general  meningitis 
(although  fortunately  very  rare)  will  at  times  obviously  be  present  and 
will  probably  j^rove  fatal  whether  we  operate  or  not." 

D.  Cases  of  New  Growth. — Mr.  Horsley  has  here,  as  in  so  many  other 
instances  connected  with  the  surger}^  of  the  central  nervous  system, 
operated  with  brilliant  success  (Med.-Gldr.  Soc,  vol.  Ixxi.  p.  383). 

The  patient  was  one  of  Dr.  Gowers',  aged  42,  and  his  chief  symptoms  were  com- 
plete paralysis  of  the  lower  limbs  and  abdomen,  the  former  being  frequently  flexed 
in  clonic  spasms,  the  pain  accompanying  these  being  extremely  severe.  There  was 
loss  of  tactile  sensibility  as  high  as,  and  involving  the  distribution  of,  the  fifth  dorsal 
nerve.  The  bladder  and  rectum  were  completely  paralysed.  The  growth  proved  to  be 
an  almond-shaped  fibro-myxoma  resting  on  the  left  lateral  column,  in  which  it  had 
formed  a  deep  bed,  and  adherent  to  the  fourth  dorsal  nerve.  The  patient  recovered 
perfectly,  the  report  being  continued  up  to  a  year  after  the  operation. 

A  great  deal  of  useful  information  may  be  obtained  from  a  paper  on 
this  subject  by  Messrs.  Putnam  and  Warren  (Amer.  Jourii.  of  Med.  Sci, 
Oct.,  1899).  The  authors  give  a  resume  of  thirty-three  cases  of  spinal 
tumour  treated  b}"  operation.  Of  these  operations  "  seven  led  to 
recovery  and  ten  to  more  or  less  improvement,  altliough  only  in  five 
of  these  latter,  amongst  which  our  first  case  was  included,  was  the 
improvement  considerable  or  lasting." 

On  the  other  hand,  fifteen  of  the  operations  were  fatal,  so  that  the 
mortalitj^  has  been  nearly  50  per  cent.,  a  fact  not  to  be  lost  sight  of 
when  this  operation  is  contemplated. 

Operation. — The  patient  being  placed  as  far  as  is  safe  in  the  prone 
position,  and  the  skin  rendered  scrupulously  clean,  an  incision  is  made 
down  to  the  spinous  processes,  with  its  centre  opposite  the  point  of 
the  angle  of  curvature,  the  site  of  the  supposed  displacement  or  disease. 
The  deep  fascia  having  been  divided  along  the  spines  and  also  trans- 
versely at  the  upper  and  lower  angles  of  the  wound,  the  tendinous 
attachments  of  the  muscles  are  cut  from  the  sjoine,  and  the  muscles 
completely  detached  from  these  processes,  the  laminge,  and  from  the 
transverse  processes  as  far  as  is  necessary,  by  the  edge  of  a  short,  stout 
scalpel.  To  prevent  hasmorrhage,  Spencer  Wells's  forceps  are  quickly 
applied,  and  then  sponges  are  tightly  packed  into  the  incision  on  one 
side  of  the  spine,  while  the  operation  is  proceeded  with  on  the  other. 
Efficient  compression  will  usually  suffice.  Any  vessels  that  require  it 
being  tied,  and  the  muscles  held  back  with  retractors,  the  periosteum  is 


PARTIAL  RESECTION   OF  THE   VERTEBR-E.  751 

reflected  with  a  suitably  curved  elevator.  Two  or  three  spinous  pro- 
cesses, if  unfractured.  are  then  cut  off  close  to  their  bases  with  powerful 
bone-forceps  with  jaws  at  different  angles.  The  laminae  may  be  next 
removed  by  spinal  saws,  aided  by  a  trephine,  but  the  most  speedy  method 
is  by  using  Mr.  Horsley's  bone-forceps  devised  for  working  at  the  bottom 
of  a  deep,  steep  wound-cavity.*  A  chisel  and  mallet  may  be  used  along 
an  already  made  saw  line,  to  complete  the  section ;  but  even  here  the 
vibrations  may  be  hurtful.  Where  the  arches  and  the  dura  mav  be 
adherent,  the  bone  must  be  removed  with  great  caution ;  "  picked  awav 
piecemeal,"  Tubby  (Orthop.  Sarr/..  p.  74).  In  the  case  of  fracture,  any 
loose  bone  will  of  course  be  tested  and  removed  b}'  sequestrum-forceps. 
The  ligamenta  subflava  are  next  cut  through  ^vith  a  sharp  knife.  The 
dura  mater,  covered  with  peculiar  vascular  fat,  is  next  exposed.  To 
avoid  troublesome  haemorrhage  from  the  numerous  veins  of  this  tissue, 
it  must  be  opened  stricth'  in  the  middle  line  and  then  kept  with  broad 
retractors  pressed  against  the  sides  of  the  spinal  canal,  while  the  dura 
mater  is  opened  (Horsley).  This  being  done  with  knife  and  dissecting- 
forceps  in  the  middle  line,  the  cerebro-spinal  fluid  escapes  freely,  and 
should  be  mopped  out  with  sponges  as  long  as  it  flows.  If  the  patient 
is  kept  quiet,  and  the  spine  horizontal,  and  the  head  not  raised,  this 
flow  will  soon  cease  (Horsley).  Any  growth  is  then  removed,  and  the 
cord  inspected  and  palpated  very  freely,  so  as  to  reveal  any  change  in 
its  density.  If  it  be  suspected  that  a  fragment  of  bone  or  a  new  gro\vth 
be  pressing  against  the  front  of  the  cord  from  one  of  the  vertebrse,  Mr. 
Horsley  advises  that  the  sides  and  anterior  aspect  of  the  cord  be  ex- 
plored by  the  careful  passage  of  an  aneurysm-needle.  Where  the  dura 
mater  has  been  opened  for  exploratory  purposes  only,  it  should  be 
sutured  ^\-ith  fine  catgut,  one  end  being  left  open.  If  any  growth  has 
been  removed  from  M-ithin,  it  ^dll  probably  be  wiser  to  provide  for 
drainage  of  the  sub-dural  space  with  horsehair.  The  extra-dural  space 
should  be  drained  with  a  small  tube. 

In  cases  of  caries,  dense  scar  tissue,  granulation  tissiie.  pus.  or  a 
tubercular  mass  may  present  themselves  when  the  dura  mater  is  ex- 
posed. In  some  it  will  be  sufficient  to  take  away  the  diseased  material, 
till  pulsation  of  the  cord  reappears  :  in  others  the  tougher  leathery 
substance  must  be  snipped  away  with  scissors  till  the  cord  is  exposed 
with  a  surface  made  as  smooth  as  possible,  and  it  is  clear  that,  if  not 
pulsating,  it  is  not  constricted.  Any  carioiis  bone  that  is  within  reach 
will  of  course  be  removed  by  the  sharp  spoon.  If.  as  is  not  unlikely, 
the  mischief — e.;/.,  tubercular  caries,  abscess  and  granulation  tissue — 
lie  in  front,  this  must  be  got  at,  if  possible,  by  drawing  the  cord 
from  side  to  side  with  an  aneurysm-needle.  cautious  removal  of  part  of 
the  transverse  processes  and  adjacent  bones.  When  all  diseased  bone, 
granulation  tissue,  &c..  has  been  removed  with  the  sharp  spoon,  a  small 
flushing  gouge  (Fig.  237).  or  gauxe  mops,  iodoform  emulsion  may  be 
applied,  and  the  greater  ])art  of  the  wound  t-losed  :  drainage  either  by 
means  of  a  tube  or  iodoform  gauze  should,  however,  be  provided  for 
twenty-four  or  forty-eight  hours,  as  oozing  may  possiblj'be  considerable. 

*  The  surgeon  should  take  the  trouble  to  be  proviiled  ^vith  the  necessary  instru- 
ments. The  ordinary  saws  and  forceps  are  quite  unfitted  for  ri'tuoving  the  laminae, 
and,  in  the  case  of  the  cervical  spine,  may.  l.y  prolonging  the  operation  and  pressing 
on  the  cord,  bring  about  a  fatal  result. 


752  OPERATIONS  OX  THE  VERTEBRAL  COLUMN. 

The  dura  mater  is  only  to  be  opened  Avhen  the  state  of  the  cord  itself 
must  be  investigated,  when  sufficient  mischief  is  not  found  outside,  or 
when  an  intra-dural  growth  exists.  This  step  is  especially  to  be  avoided 
in  tubercular  cases,  as  it  may  cause  a  tubercular  meningitis  (Chipault). 

Causes  of  Failure  and  Death  after  Laminectomy,  &c. — (i)  Shock.  As 
I  have  already  stated,  the  failure  of  the  surgeon  to  supply  himself  with 
proper  instruments  may  lead  to  needless  prolongation  of  the  operation 
and  pressure  on  the  theca  which,  especially  in  operations  on  the  cervical 
region,  may  help  to  bring  about  a  fatal  result.  (2)  Hfemorrhage. 
This  seems  to  have  been  rarely  troublesome ;  the  extra-dural  plexus 
appears  to  be  usually  obliterated  in  cases  of  Pott's  curvature.  According 
to  Chipault  haemorrhage  has  no  special  interest  in  the  lumbar  and  dorsal 
regions,  in  the  neck  it  is  much  more  serious,  since  death  has  resulted 
three  times  from  a  lesion  of  the  vertebral  artery.  (3)  Respiratory 
trouble,  probably  largely  due  to  the  prolonged  anesthetic.  In  one  case 
(Deaver,  Inter,  journ.  Med.  Sci.,  Dec,  1888)  the  respiration  became  much 
embarrassed  towards  the  end  of  the  operation ;  this  continuing  till  the 
patient's  death  three  days  later,  was  attributed  to  injury  to  the  phrenic 
nerve  with  an  exploring  needle.  The  dura  mater,  thickened  and  ad- 
herent to  the  base,  had  been  thus  explored  after  removal  of  the  third 
and  fourth  cervical  arches  which  were  carious.  (4)  Septic  complications. 
(5)  Tubercular  or  other  secondar}-  deposits  elsewhere.  (6)  Temporary 
improvement  followed  by  a  relapse. 


TAPPING    THE    SPINAL    THECA. 

This  step  was  advised  by  Quincke  as  a  means  of  relieving  pressure 
symptoms  in  acute  and  chronic  hydrocejohalus,  and  also  to  aid  in  the 
diagnosis  between  serous,  purulent  and  tubercular*  meningitis.  The 
interval  between  the  third  and  fourth  lumbar  spines  is  taken,  and  the 
theca  is  found  at  a  depth  of  four  centimetres.  Albertin  (Lyon.  Med  , 
October  8.  1899)  reports  a  most  interesting  case,  which  serves  to  illus- 
trate the  usefulness  of  this  measure  in  relieving  intra-spinal  pressure 
in  certain  cases  : — 

A  man  fell  from  a  window,  striking  his  knees  and  then  his  back.  Paraplegia  was 
the  immediate  result,  the  reflexes  were  absent,  and  there  were  large  areas  of  cutane- 
ous anaesthesia.  The  sphincters  were,  however,  unaffected.  Fourteen  days  later 
Albertin  inserted  a  trocar  into  the  spinal  canal  in  the  lumbar  region,  and  drew  ofE 
one  ounce  of  blood-stained  fluid.  Forty-eight  hours  later  the  reflexes  had  returned, 
and  from  this  time  slow  improvement  took  place,  so  that  two  weeks  later  the  patient 
could  walk  with  crutches.     The  final  result  is  not  given. 

Spinal  Ansesthesia.-r-Since  Dr.  Leonard  Corning,  of  Xew  York, 
discovered  this  method  of  inducing  angssthesia  in  1885,  it  has  been 
given  an  extended  trial,  and  a  large  number  of  cases  have  been  recorded, 
so  far  according  to  Drs.  William  White  and  F.  D.  Patterson  (Amer. 
Journ.  of  Med..  Sci.,  1901,  p.  227!),  without  a  single  death  due  to  the 

*  Flirbringer  found  tubercle  bacilli  in  twenty-seven  out  of  thirty-seven  cases  of 
tubercular  meningitis,  one  of  which  is  stated  to  have  ended  in  recovery  (^Berlin  Clin. 
Woch.,  Nov.  13,  1893). 

t  Where  a  useful  account  is  given,  and  from  which  most  of  what  follows  has  been 
drawn. 


PARTIAL  llESECTIOX  OF  THE   VEKTEBR.E.  753 

anesthetic.  Sequen  and  Kendirdjy  (Presse  Med.,  Oct.  27,  1900)  report 
fifty-seven  cases,  in  all  but  two  of  which  the  anaesthesia  was  perfect. 
Tuffier  (Presse  Med.,  Nov.  7,  1900)  reports  210  successful  cases,  II2 
of  which  were  intra-peritonaeal  operations. 

Complete  angesthesia  below  the  level  of  the  umbilicus  is  produced  in 
from  four  to  ten  minutes  after  the  injection,  and  lasts  for  an  hour  to 
an  hour  and  a  half.  As  regards  after-effects,  vomiting  is  frequent,  also 
severe  headache ;  in  a  few  cases  also  transient  paraplegia  and  retention 
of  urine  have  occurred.  The  greatest  objection  to  the  employment  of 
the  method  is  undoubtedly  the  verj^  grave  danger  of  sepsis,  and  it  is  the 
fear  of  this  which  will  probabl}^  prevent  any  general  adoption  of  the 
plan.  The  question  of  safety  apart  from  sepsis  is,  moreover,  certainly 
not  settled  at  present.  Drs.  White  and  Patterson  (loc.  supra  cit.)  say : 
"  In  conclusion,  it  may  be  said  that  although  no  deaths  have  so  far  been 
reported  from  this  method,  it  still  remains  to  be  shown  that  sub- 
arachnoid cocainisation  is  safer  than  general  antBsthesia  ;  in  fact,  it  is 
very  questionable  if  it  is  as  safe.  The  puncture  of  the  spinal  canal 
itself,  not  to  mention  the  injection  of  cocaine,  is  not  without  its  danger, 
as  has  been  shown  by  Gumprecht  (Deutsche  Med,.  Woch.,  1900,  vol.  xxvi. 
p.  386),  who  reports  seventeen  cases  of  sudden  death  following  simple 
lumbar  puncture  for  diagnostic  purposes." 

Operation. — The  greatest  care  must  be  exercised  to  maintain  asepsis. 
The  patient's  skin  must  be  carefully  prepared  beforehand,  and  the  sur- 
geon's hands  cleansed  as  for  a  major  operation.  The  instruments  and 
cocaine  or  eucaine  solution  must  also  be  sterile.  Mr.  Priestle}'  Leech 
(Med.  Annual,  1901)  describes  the  technique  as  follows: — The  patient 
is  laid  on  one  side,  say  on  the  left  side,  he  is  told  to  round  his  back, 
flexing  the  legs  on  the  thighs  and  the  thighs  on  the  abdomen,  and  a 
cushion  is  placed  underneath  his  flank.  In  this  way,  the  spinous  pro- 
cesses of  the  vertebi'as  are  separated  to  the  greatest  extent,  the  space 
between  being  one  and  a  half  centimetres  (nine-sixteenths  of  an  inch). 
The  lumbar  region  is  then  cleansed.  The  surgeon  then  feels  the  pos 
terior  inferior  iliac  spines  situated  below  the  great  sciatic  notch  ;  he 
joins  the  spines  by  a  transverse  line  which  passes  at  the  level  of  the 
fifth  lumbar  vertebra ;  it  is  below  this  line  he  will  look  for  the  sacro- 
lumbar  fossa,  and  from  this  point  count  the  lumbar  spinous  processes 
till  he  reaches  the  third  or  fourth  lumbar  interspace,  which  is  the  seat 
of  election.  When  the  seat  of  election  has  been  determined,  it  is 
marked  with  tincture  of  iodine,  and  the  skin  is  rendered  anoesthetic 
by  means  of  ethyl  chloride ;  this  prevents  any  involuntary  movement 
which  would  bring  the  processes  together.  The  needle  should  be  strong, 
three  and  a  quarter  inches  to  four  inches  in  leiigth;  in  thin  young 
children  an  ordinary  hypodermic-needle  suffices,  but,  as  a  rule,  it  is  too 
short  and  fragile. 

The  surgeon  now  finds  the  spinous  process  corresponding  to  the  space 
selected  (the  thii-d  or  fourth  lumbar  space);  keeping  his  finger  on  the 
spinous  process  he  now  inserts  the  needle  half  a  centimetre  to  its  outer 
side  to  the  right  or  left  of  the  middle  line  as  the  cast^  may  be.  The 
needle  is  held  between  the  thumb  and  index  finger  of  the  right  hand, 
and  pushed  without  violence  from  behind  forwards,  from  without 
inwards  and  from  below  upwards  ;  these  directions  must  not  be  ex- 
aggerated ;  the  obliquity  of  the  needle  upwards  and  inwards  must  be 
VOL.  II.  48 


754  OPERATIONS  OX  THE   VERTEBRAL  C0LU3IN. 

very  slight.  The  needle  may  be  ari'ested  by  something  resistant,  i.e., 
one  of  the  two  bony  laminae,  and  it  is  nearly  always  the  superior  lamina 
of  the  space  the  surgeon  wishes  to  traverse.  The  needle  mvist  be  with- 
drawn a  little,  and  pushed  in  another  direction.  When  the  surgeon  has 
traversed  the  inter-laminar  space  he  must  watch  the  external  orifice  of 
the  needle,  as  a  drop  of  cerebro-spinal  fluid  wells  up  as  soon  as  the 
sub-arachnoid  space  has  been  reached.  The  escape  of  cerebro-spinal 
fluid  is  the  sign,  without  which  cocaine  must  never  be  injected.  When 
eight  or  ten  drops  of  cerebro-spinal  fluid  have  welled  up  through  the 
needle,  the  time  has  come  to  inject  the  cocaine.  .  .  .  The  injection 
must  be  made  very  slowly,  the  solution  must  be  freshly  prepared,  the 
temperature  of  the  solution  must  be  about  37°  C,  and  the  quantity  of 
cocaine  injected  must  never  exceed  four  centigrammes.  The  solution 
must  be  a  weak  one,  either  i  in  100,  or  i  in  200  ;  eight  cubic  centi- 
metres of  a  I  in  200  solution  would  represent  four  centigrammes  of 
cocaine. 


INDEX     OF     XAMES. 


AX)  L  U  M  E     II. 


Abbe  (R.)-  renal  sarcoma,  144  ;  nephrectomy,  148  ;  Murphy's  button.  238,  239 ;  enteror- 
raphy,  240;  intestinal  anastomosis,  269;  modification  of  Kader's  method  of 
gastrostomy,  303;  "string"  method  of  treating  oesophageal  stricture.  305; 
drainage  after  choledochotomy.  362  ;  suppuration  after  injection  of  carbolic  into 
a  hydrocele  sac.  466 

Abeexethy.  incision  for  ligature  of  external  iliac.  4 

Adams,  case  of  pylorectomy.  323,  324 ;  osteotomy  of  femur.  722 

Albarran.  papilloma  of  ureter.  146  ;  growths  of  the  bladder.  380 

Albert,  method  of  gastrostomy.  302 

Alexander,  method  of  prostatectomy.  3S9 

Alexandrow.  litholapaxy  in  male  children,  423 

Allingham  (W.).  surface  marking  of  the  colon.  94 

Allingham  (H.  W.).  lumbar  colotomy.  96 ;  inguinal  colotomy.  105.  107  :  enteroplasty. 
279;  artificial  anus  in  the  transverse  colon,  112;  perforating  typhoid  ulcer.  212  • 
bone  bobbin.  243  ;  ligature  for  haemorrhoids,  490  ;  screw  crusher  for  hfemorrhoids'. 
492  ;  hemorrhage  after  operation  for  hasmorrhoids.  494 ;  complications  after 
operations  for  haemorrhoids,  495 ;  vulcanite  tube  for  use  after  excision  of  the 
rectum,  501 ;  partial  excision  of  the  rectum,  506 ;  excision  of  the  rectum  bv  the 
abdomino-perinajal  route.  515 ;  internal  derangements  of  the  knee.  657 

Alsberg.  stricture  of  the  ureter.  170 

Amussat,  colotomy.  85 

A^TDERSON  (of  Nottingham),  suture  of  the  bladder  after  supra-pubic  lithotomy.  404 

Anderson  (W.).  case  of  papilloma  of  the  bladder,  375 ;  ectopia  vesicae.  449 

Andrews,  gastrotomy  for  hemorrhage.  309.  310 

Annandale,  case  of  gunshot  wound  of  the  abdomen.  290;  internal  derangements  of 
the  knee,  657.  65S 

Anson,  perforated  gastric  ulcer,  204 

Arnold  (W.  E.).  amputation  at  the  hip-joint,  578 

ASHURST,  mortality  of  amputations  at  the  hip-joint  by  Wyeth's  method.  582 

Baer  (B.  F.).  conservative  surgery  of  the  uterine  appendages.  547 ;  supra-vaginal 
hysterectomy,  557 

Bailey  (11.),  bone  tube  for  enterorraphy,  245 

Baker  (Morrant).  ligature  of  common  iliac  for  hemorrhage.  14 ;  lumbar  colotomy 
for  imperforate  anus.  89  ;  method  of  fixing  the  bones  after  knee  excision.  646 

Baldy,  ovariotomy,  529  ;  removal  of  uterine  appendages,  546 ;  vaginal  hysterectomy,  563 

Ball,  radical  cure  of  inguinal  hernia,  70 ;  radical  cure  of  umbilical  hernia,  83  ;  results 
of  excision  of  the  rectum,  500  ;  sutures  after  excision  of  the  rectum,  505  ;  question 
of  colotomy  before  excision  of  the  rectum,  516 

Ballance,  enterorraphy,  254;  splenectomy  for  injury.  342;  dressing  after  circum- 
cision, 458 

Bakgs  (L.  B.),  treatment  of  tubercular  disease  of  the  bladder.  386 


756  INDEX  or  NAMES. 

Banks  (W.  M.),  ligature  of  external  iliac  by  abdominal  section.  24  ;  ligature  of  the 
abdominal  aorta.  30  ;  strangulated  hernia,  41  ;  radical  cure  of  hernia.  54  ;  enormous 
hernise,  61  ;  operation  for  radical  cure  of  hernia,  71  ;  treatment  of  artificial  anus,  276 

Baebouk.  foreign  body  in  the  female  bladder.  424 

Bardenheuer.  complete  extirpation  of  the  bladder,  384 

Barette,  partial  intestinal  resection,  263 

Barker,  wound  of  obturator  artery,  42 ;  radical  cure  of  umbilical  hernia,  50,  83  ; 
method  of  radical  cure  of  hernia,  72  ;  radical  cure  of  femoral  hernia,  79  ;  inguinal 
colotomy,  106;  ruptured  kidney.  145;  nephrectomy.  150;  abdominal  nephrectomy, 
152;  rupture  of  ureter,  170;  intussusception,  181,  184;  appendicitis,  196;  per- 
forated gastric  ulcer,  207  :  gunshot  wounds  of  abdomen,  291  ;  pylorectomy  in  two 
stages.  314;  case  of  gastro-jejunostomy,  329  ;  condition  of  limb  after  hip  excision, 
594 ;  excision  of  the  hip,  599,  600 ;  semilunar  incision  for  excision  of  the  knee, 
642  ;  excision  of  the  knee.  645 

Barlikg  (G.),  appendicitis.  193 

Barnard,  gunshot  wounds  of  the  intestine,  281 ;  gunshot  wounds  of  the  duodenum,  284 

Barth,  partial  nephrectomy,  158;  nephrorraphy,  164 

Bartlett,  secondary  hjemorrhage  from  common  femoral  artery,  3 

BaewelL,  ligature  of  the  abdominal  aorta.  30 ;  vesico-vaginal  fistula  after  extraction 
of  calculus,  427  ;  osteotomy  of  tibia,  727 

Bassini,  radical  cure  of  inguinal  hernia,  56,  63  ;  radical  cure  of  femoral  hernia,  81 

Battle,  nephro-lithotomy,  132 ;  ruptured  intestine,  292.  294 ;  tuberculosis  of  the 
bladder,  386 

Baudet,  ligature  of  the  internal  iliac,  20 

Beck,  cancer  of  the  pancreas,  91 

Belfield,  prostatectomy,  388 

Bell  (J.),  ligature  of  the  gluteal  artery,  27  ;  treatment  of  tuberculosis  of  the  bladder,  386 

Bellamy,  multilocular  hernial  sac,  43 

Bennett  (W.  H.),  strangulated  hernia.  33  ;  abdominal  section  for  hernia,  53  ;  method 
of  radical  cure.  73  ;  radical  cure  of  femoral  hernia.  79  ;  radical  cure  of  umbilical 
hernia,  83  ;  perforated  gastric  ulcer.  208 ;  supra-pubic  aspiration,  432  ;  operation 
for  varicocele.  473  ;  recurrence  of  varicocele,  476 

Berg,  ureteral  calculus,  169 

Bergmann,  nephrectomy.  148 

BiDWELL,  case  of  gastro-jejunostomy  by  suture.  328 ;  method  of  suture  after  excision 
of  the  rectum.  505 

Bier,  ligature  of  the  internal  iliac  for  enlarged  prostate,  19 

BiGELOW,  lithotrite.  415;  time  occupied  in  litholapaxy,  419 

BiNNlE,  cholecystostomy.  358 

Bird  (C.  H.  Golding),  colotomy  for  membranous  colitis,  90  ;  case  of  jejunostomy  for 
cancer  of  the  pylorus,  340 ;  arthrectomy  for  sacro-iliac  disease,  577  ;  trans-patellar 
excision  of  the  knee-joint,  642 

BiRKETT,  strangulated  obturator  hernia.  51 

Bishop  (E.  Stanmore).  method  of  radical  cure  of  hernia,  74  ;  hernia  after  hyster- 
ectomy. 558 

Bond,  suture  of  the  bladder  after  supra-pubic  lithotomy,  404  ;  supra-pubic  cys- 
totomy, 428 

BouiLLY,  enterectomy,  266 

BOUISSON.  treatment  of  hypospadias,  452 

BoVEE,  suture  of  ureter,  170 

BowLBY,  granular  kidney,  120;  euterorraphy,  243  ;  nerve  suture,  736 

Boyd,  enterorraphy,  234 

Bradford  (E.  H.).  results  of  operation  for  congenital  dislocation  of  the  hip,  606 

Bramwell  (J.  P.).  nerve  stretching  for  sciatica,  740 

Brashear  (W.),  amputation  at  the  hip-joint.  578 

Braun,  wound  of  the  femoral  vein,  609 

Briddon  (C),  injuries  of  the  kidney,  145  ;  case  of  gunshot  wound  of  the  abdomen,  291  ; 
cholecystenterostomy,  367 

Beiggs  (W.  T.).  advantages  of  median  lithotomy,  407 ;  modification  of  median 
lithotomy,  408 

Brinton.  obstruction  of  the  large  intestine,  92  ;  amputation  through  the  knee-joint,  6^^ 

Brodie  (Sir  B.).  villous  tumour  of  the  bladder,  375  ;  hypertrophied  prostate,  388 

Brown  (Tilden),  nephrectomy,  154 ;  air  distension  of  the  bladder,  402 

Brown  (W.  H.),   ligature  of  external  iliac  by  abdominal  section,   24;    supra-pubic 

Browne  (Buckston),  case  of  prostatectomy,  391 
aspiration,  432 

Bruns,  results  of  hip  excision,  594  ;  mortality  after  hip  excision,  602  ;  excision  of  the 
knee,  639 

Bryant,   lumbar   colotomy,  94,  96,  97 ;    inguinal  colotomy,   102  ;    appendicitis,  194 ; 


INDEX  OF  NAMES.  757 

injury  to  the  portal  vein  in  tapping  a  hydatid  of  the  liver.  347;  case  of  growth  of 
the  bladder.  380 ;  removal  of  growths  of  the  bladder.  385;  lateral  lithotomy  in 
children,  423  ;  puncture  per  rectum,  433  ;  cases  of  ligature  of  the  femoral  artery 
for  haemorrhage,  613 

Buchanan,  ligature  of  external  iliac  for  elephantiasis,  3 

Buck  (G.),  appendicitis,  200 

Boll,  radical  cure  of  hernia,  54.  56,  59  ;  case  of  gunshot  wound  of  the  abdomen,  291  ; 
antiseptic  incision  for  hydrocele.  466 

BusACHi.  implantation  of  the  ureter  into  the  bladder,  172 

BuscH,  appendix  in  a  hernial  sac,  62 

Butcher,  ligature  of  the  common  femoral  artery.  611 

Butler,  suppression  of  urine,  140 

BUTLIN,  renal  calculus,  115;  renal  sarcoma.  143;  enterectomy,  256;  pain  after  gas- 
trostomy, 305  ;  mortality  after  pylorectomy,  315  ;  feeding  after  pylorectomy,  325  ; 
malignant  disease  of  the  testis,  477 

BuTZ,  vegetable  plates  for  euterorraphy,  248 

Cabot,  ureteral  calculus,  169  ;  tamponnade  of  the  bladder  for  haemorrhage,  382 

Cadge,  lateral  lithotomy.  394,  396.  398 ;  median  lithotomy,  407 ;  recurrence  after 
lithotrity,  412  ;  comparison  of  old  and  new  operations  of  lithotrity,  419 

Caird,  enterectomy,  262,  265  ;  partial  resection  of  intestine,  263  ;  case  of  pancreatic 
cyst,  372 

Callisen,  colotomy,  85 

Campbell,  peritonitis  after  supra-pubic  aspiration  of  the  bladder,  432 

Campenox.  vaginal  excision  of  the  rectum,  514  ■ 

Carden,  amputation  above  the  knee-joint,  625 

Carle,  gastro-jejunostomy,  332 

Cathcart,  Murphy's  button,  236;  pancreatic  cysts,  370;  method  of  draining  the 
bladder,  383,  405 

Cayley,  perforation  of  typhoid  ulcer,  212 

Cazin,  gastrotomy  for  hiemorrhage,  308 

Ceci,  ureteral  calculi,  169 

Champneys,  indications  for  the  removal  of  the  uterine  appendages,  539 

Chevalier,  resection  of  the  bladder,  384 

Cheyne  (Watson),  needles  for  use  in  the  radical  cure  of  hernia,  67  ;  movable  kidney, 
120;  tubercular  peritonitis,  219 

Chlumsky,  spur  formation  after  gastro-jejunostomy.  339 

CivlALE,  internal  urethrotomy.  446 

Clado,  complete  extirpation  of  the  bladder,  384 

Clarke  (Bruce),  hydronephrosis,  119;  nephro-lithotomy,  127:  speculum  for  the 
bladder,  379 ;  encysted  vesical  calculus,  399  ;  wound  of  peritonaeum  in  supra-pubic 
lithotomy,  406 

Glutton,  femoral  aneurysm.  2;  Meckel's  diverticulum,  179;  intestinal  obstruction 
by  gall-stones,  186;  imperforate  anus,  519;  erasion  of  the  ankle  by  lateral  in- 
cisions, 701 ;  cases  of  spina  bifida  treated  by  excision,  744 

Cock,  anuria  from  a  ruptured  single  kidney,  140;  perinaeal  section,  433.  437,  440; 
case  of  carcinoma  testis,  478 

CoLEY,  radical  cure  of  hernia,  54,  56,  59 

Colley  (Davies),  lumbar  colotomy,  97;  villous  tumour  of  the  bladder,  376;  cir- 
cumcision, 457  ;  operative  treatment  of  varicose  veins,  684 

Collier,  arthrectomy  for  sacro-iliac  disease,  577 

Cooper  (Sir  Astley),  incision  for  ligature  of  external  iliac,  4  ;  secondary  haemorrhage 
after  ligature,  9  ;  ligature  of  the  abdominal  aorta,  30;  strangulated  hernia,  41 

Cooper  (Bransby),  ligature  of  the  femoral  artery.  613 

COUPER,  vomiting  after  lumbar  colotomy,  loi 

CouPLAND,  distension  ulcers  of  the  caecum,  loi 

Courvoisieb,  modification  of  gastro-jejunostomy,  336 

Cbampton,  p.,  incision  for  ligature  of  common  iliac,  16 

Cripps,  inguinal  colotomy,  103,  104 ;  dilator  for  colotomy  opening,  108 ;  intestinal 
obstruction,  176;  Murphy's  button,  239;  fistula  in  ano,  487 ;  indications  for  ex- 
cision of  the  rectum,  498  ;  the  cautery  in  excision  of  the  rectum,  504  ;  ulceration 
of  the  femoral  vessels,  610;  treatment  of  stab  wound  in  mid  thigh,  617  ;  ligature 
of  the  posterior  tibial,  663 

Croft,  hydronephrosis,  142  ;  rupture  of  the  ureter,  170  ;  rupture  of  the  intestine.  292  ; 
two  cases  of  ruptured  intestine  without  external  wound,  294 ;  plaster-of-Paris 
splint,  680 

Cullingwobth,  indications  for  removal  of  uterine  appendages,  540;  removal  of 
uterine  appendages,  545  ;  hernia  after  hysterectomy,  558 

CUMSTON,  nephro-lithotomy,  125 ;  operation  for  prolapse  of  the  rectum,  497 


758  INDEX  OF  NAMES. 

CURLIXG,   colotoniy,   89;   lumbar  colotomy,  98;  carcinoma  testis,  478;  treatment  of 

fistula  in  ano,  489  ;  treatment  of  anal  fissure,  495 
Curtis.  B.  F..  ruptured  intestine.  291 
Curtis  (Farquhae),  gastroplication.  340 
CZERNY.  nephrectomy,  153;    ureteral  calculus,  169;   gastro-jejunostomy  by  Murphy's 

button,  330 ;  results  of  excision  of  the  rectum,  500 

Daltok',  case  of  gunshot  wound  of  the  stomach  and  liver,  285 

Davy,  rectal  lever,  582  ;  splint  for  use  after  tarsectomy,  713 

Dawbarx.  Murphy's  button.  238  ;  vegetable  plates  for  enterorraphy.  248 

Day  (D.),  renal  calculus,  129 

Delegarde,  Chopart's  amputation.  714 

Dennis,  ligature  of  iliac  arteries  by  an  abdominal  incision,  22  ;  case  of  gastrostomy,  300 

Dickinson,  renal  carcinoma,  143 

DiTTEL,  supra-pubic  route  for  removal  of  bladder  growths,  378 

Diver,  ligature  of  external  iliac,  2 

DoLBEAU,  perineal  lithotrity,  421 

DoRAN.  incision  for  ovariotomy,  529 ;  incomplete  ovariotomy,  537 ;  oophorectomy  for 

uterine  fibro-myomata,  541  ;  treatment  of  uterine  fibro-myomata,  557 
Deummond,  movable  kidney.  163.  166 

DuJARlER.  case  of  complete  extirpation  of  the  bladder,  384 
DUMREICHER,  uephro-lithotomy,  123 
Duncan  (M.),  pyelitis,  119;  aching  kidney,  120;  incision  for  exploration  of  the  bile 

ducts.  354     " 
Dunn,  case  of  perforating  gastric  ulcer,  205 
DUPLAY,  operation  for  hypospadias,  451 
DuPUYTREX,  strangulated  hernia,  41 ;  wound  of  the  obturator  artery,  42  ;  excision  of 

the  rectum.  503 
Durham,  form  of  oesophageal  bougie,  298  ;  electrolysis  for  hydatids  of  the  liver,  349 

Edebohls,  exploration  of  the  "  other  "  kidney.  141 

Edmunds,  comparison  of  methods  of  enterorraphy,  254 

EisENDEATH,  gastrotomy  for  liEemorrhage,  309 

Emmett,  ureteral  calculus.  169 

Erichsen,  wound  of  external  iliac,  3  ;  strangulated  hernia,  41 ;  strangulated  obturator 
hernia,  52 ;  lateral  lithotomy.  393 ;  difSculties  in  lateral  lithotomy,  399  ;  median 
lithotomy.  407 ;  treatment  of  vesical  calculus  in  the  female,  424 ;  treatment  of 
femoral  aneurysm,  611 ;  ligature  of  the  femoral  artery,  6ig 

Eve,  intussusception,  181  ;  intestinal  obstruction  by  gall-stone,  186 ;  perforated  duo- 
denal ulcer,  210 

Eve  (of  Tennessee),  amputation  at  the  hip-joint,  578 

EwAET,  perforated  gastric  ulcer,  20S 

Ewens,  cuneiform  tarsectomy,  712 

Fagge,  obstruction  of  the  large  intestine.  92;  solvent  treatment  for  calculi.  117; 
renal  tuberculosis,  141;  septic  peritonitis,  213;  aspiration  for  hydatids  of  the 
liver,  347 

Farabeuf,  ligature  of  the  anterior  tibial,  671 ;  excision  of  the  os  calcis,  705 

Fehling,  removal  of  the  ovaries  for  osteomalacia,  543 

Fenger,  hydronephrosis  due  to  stricture  of  the  ureter.  119;  operation  for  valvular 
obstruction  of  the  ureter,  169;  stricture  of  the  ureter,  170 

Kenwick,  renal  htematuria,  113;  treatment  of  growths  of  the  bladder,  381  ;  case  of 
partial  resection  of  the  bladder,  383  ;  rupture  of  the  bladder  by  injection  of  fluid, 
385  ;  encysted  vesica   calculus,  404  ;  castration  for  enlarged  prostate,  480 

Febgusson  (Sir  AV.),  rupture  of  aneurysm  by  manipulation,  8 ;  case  of  lateral  litho- 
tomy. 395 ;  lithotrity,  409 

Finney,  volvulus,  1S5  ;  perforated  gastric  ulcer.  204.  208  ;  septic  peritonitis,  217 

Fitz,  acute  pancreatitis,  373 

Fontino,  gastro-jejunostomy,  332 

Footneb,  renal  calculus,  129 

Fowler,  appendicitis,  194,  196,  199,  203  ;  operation  for  fractured  patella,  653 

Franck.  method  of  performing  gastrostomy,  303 

Francke,  pylorectomy  in  two  stages,  314 

Franks,  nephro-lithotomy,  125 ;  case  of  obstruction  of  lower  end  of  oesophagus  treated 
by  gastrotomy,  305 

Feasee,  suppression  of  urine,  137 

Freyer,  complete  removal  of  the  prostate,  390 ;  lithotrity  for  large  stones,  409  ; 
lithotrity,  417  ;  vasectomy  for  enlarged  prostate.  486 

Fuller,  prostatectomy,  389,  391 


INDEX  OF  NAMES.  759 

Galabix,  vesical  calculus  in  the  female,  424;  ruptured  periiiajum,  521;  vaginal 
hysterectomy,  565  ;  Ciesarian  section,  570 

Gant,  osteotomy  of  femur,  723 

Gardner,  modification  of  Phelps'  operation,  709 

Gerhardt.  thrombosis  of  mesenteric  vessels,  187 

Gerster,  appendicitis,  199;  excision  of  the  rectum,  513 

Gersuny,  torsion  of  the  rectum  after  excision,  501,  512 

GiBNEY.  treatment  of  hip  disease,  591 ;  results  of  operations  for  congenital  dislocation 
of  the  hip,  606 

Gibson,  acute  intestinal  obstruction,  174;  gangrenous  hernia,  255  ;  enterectomy,  262 

GiRALDfis,  position  of  the  sigmoid  in  imperforate  anus,  90 

Gluck.  bone  tubes  for  use  in  nerve  suture,  737 

GoDLEE.  renal  calculus.  122 

GooDHART.  renal  calculus,  130;  intussusception,  181  ;  appendicitis,  192 

Gould  (A.  Pearce).  perforated  gastric  ulcer,  205.  208  ;  lavage  of  the  stomach,  310; 
pyloroplasty,  312;  mortality  of  pyloroplasty,  314;  surure  of  a  pancreatic  cyst, 
372  ;  amputation  of  the  penis,  463  ;  wound  of  the  common  femoral  vein,  609 

GouLEY.  modification  of  median  lithotomy,  408 

Gow,  mortality  of  hysterectomy,  558 

Graefe.  enterectomy,  268 

Green  (King),  gastrostomy  in  a  case  of  cancer  of  the  pharynx,  296 

Griffiths,  dysmeuorrhoea.  542 

Gritti,  trans-condyloid  amputation  above  the  knee.  627 

Gross,  difficulty  in  lateral  lithotomy  due  to  enlarged  prostate,  398 

GUNIARD.  gastrotomy  for  hasmorrhage.  308 

GUNTHER.  modification  of  Pirogoff's  amputation,  694 

Gussenbauer.  frequency  of  adhesions  in  cancer  of  the  pylorus,  315 ;  complete  extir- 
pation of  the  bladder,  384  ;  peritonteum  in  supra-pubic  lithotomy,  406 

Guthrie,  case  of  pulsating  tumour  of  the  buttock.  13 

GUYON.  villous  tumour  of  the  bladder.  376;  growths  of  the  bladder,  377;  use  of  the 
cautery  in  operations  for  bladder  growths,  381  ;  cases  of  tubercular  disease  of  the 
bladder,  386  ;  hasmorrhage  in  supra-pubic  lithotomy,  403 

Hagen.  splenectomy  for  sarcoma,  343  ;  results  of  splenectomy,  344 

Hagenbach,  case  of  stricture  of  the  lower  end  of  the  oesophagus,  305 

Haggard,  case  of  Loreta's  operation,  310 

Hague,  supra-pubic  aspiration,  432 

Hahn.  pylorectomy  in  two  stages.  314;  cases  of  jejunostomy.  340 

Hall  (W.),  perforating  gastric  ulcer.  204 

Halsted,  method  of  radical  cure  of  hernia,  75  ;  intestinal  suture.  229 ;  intestinal 
anastomosis,  254,  271  ;  metal  hammer  for  use  in  suturing  the  common  bile  duct,  361 

Hamilton,  case  of  gunshot  wound  of  the  abdomen,  291 

Hancock,  excision  of  the  ankle.  699 

Harley,  enterorraphy.  233 

Harris  (M.  L.).  operation  for  traumatic  dislocation  of  the  hip,  603 

Harrison  (  Damer).  cases  of  nerve  grafting,  738 

Harrison  (H.).  shock  after  removal  of  tumours  of  the  bladder.  385 ;  cystotomy,  428 ; 
puncture  through  the  prostate,  434 

Harrison  ( Pt.),  villous  tumour  of  the  bladder.  375 :  recurrence  after  lithotrity,  413; 
time  taken  in  lithotrity,  419  ;  repeated  washings  after  lithotrity,  420  ;  perinaeal 
lithotrity,  421;  treatment  after  internal  urethrotomy,  446;  vasectomy  for 
enlarged  prostate,  486 

Hart,  foreign  body  in  the  female  bladder,  424 

Harvie  (of  New  York),  case  of  complete  gastrectomy,  326 

Haslam.  question  of  colotomy  before  excision  of  rectum.  516 

Hatch,  hiemorrhage  after  splenectomy,  345 

Haward,  renal  calculus.  133 

Hawkins  (C^sar).  carcinoma  testis,  477 

Hawkins  (F.).  volvulus.  185 

Hawkins  (H.  P.).  appendicitis,  189;  tuberculous  peritonitis,  219 

Hayes,  bone  bobbin  for  enterorraphy,  245  ;  case  of  Tripier's  amputation,  715 

Heath,  inguinal  colotomy,  106.  iii^;  ligature  of  the  anterior  tibial,  670;  nerve  graft- 
ing, 738 

Heigl.  vegetable  plates  for  enterorraphy,  248 

Heinecke.  pvloroplasty,  312  ;  sacral  resection  in  excision  of  the  rectum,  510 

Helferich,  resection  of  the  bladder.  384  ;  results  of  carbolic  injection  for  hydrocele, 
466 

Herezel,  ectopia  vesicae,  448 

Herman,  treatment  of  the  omentum  in  ovariotomy,  531  ;  suture  of  the  abdominal  wall, 


^60  INDEX  OF  NAMES. 

533  ;   drainage  after  ovariotomy,  535  ;  removal  of  the  uterine  appendages.  541 ; 

supra-vaginal  hysterectomy,  557 ;  vaginal  hysterectomy,  563  ;    Cassarian  section, 

571  ;  Porro's  operation,  573 
Hewson,  advantages  of  Pirogotf's  amputation,  6gi 
Hey,  wound  of  the  obturator  artery,  42  ;   amputation  through  the  tarso-metatarsal 

joints,  717 
Hicks,  rupture  of  the  ureter,  170 
Hill  (Berkeley),  internal  urethrotomy,  444 ;  treatment  after  internal  urethrotomy, 

446  ;  injection  of  carbolic  for  hydrocele,  467 
Hilton,   double   aneurysm,   2 ;    strangulated    obturator  hernia,   52 ;    phimosis,   456 ; 

"  white  line  "  at  the  anus,  493  ;  treatment  of  anal  fissure,  495  ;  arthrectomy  for 

sacro-iliac  disease,  577  ;  necrosis  in  hip  disease,  592 
HiNGSTON,  lithotrity,  410 
HocHENEGG,  excision  of  the  rectum,  512 

HoFPA,  operation  for  congenital  dislocation  of  the  hip,  605  ;  excision  of  the  knee,  644 
HoLDEN,  ilio-femoral  aneurysm  cured  by  pressure,  2  ;  surface  marking  of  the  meta- 

tarso-phalangeal  joints,  720 
HoLL,  relation  of  the  last  rib  to  the  pleura,  123 
Holmes,  ilio-femoral  aneurysm,  i  ;  ligature  of  common  iliac,  10  ;  pulsating  tumours 

simulating  aneurysm,  14  ;    gluteal  aneurysm,   26 ;    multilocular   hernial  sac,  44  ; 

colotomy  for  recto-vesical  fistula,  89;  Loreta's  operation  for  pyloric  stenosis,  310; 

case  of  lateral  lithotomy,  392 ;  deficient  rectum,  517  ;  condition  of  the  limb  after 

hip  excision,  593;  ligature  of  the  common  femoral,  611;  value  of  the  limb  after 

excision  of  the  knee,  635  ;  ligature  of  the  popliteal  artery,  661  ;  early  sub-periosteal 

resection  for  necrosis,  678  ;  excision  of  the  ankle,  697  ;  excision  of  the  oscalcis,  705  ; 

excision  of  tarsal  bones,  706 
Hoerocks,  intestinal  resection,  248 

Horsley,  nerve  stretching  for  reflex  epilepsy,  and  for  infantile  paralysis,  740 
Howell,  results  of  nerve  suture,  735 
Howse,  colotomy,   88;   lumbar    colotomy,  97;    nephro-lithotomy,    124;    operation   of 

gastrostomy,  299  ;  feeding  after  gastrostomy,  304  ;    case  of  traumatic  stricture  of 

the    urethra,  428 ;    circumcision,  457 ;  excision  of   varicocele,  472  ;    excision    of 

the  knee-joint,  635,  640,  646 ;  sequestrotomy,  676 
HuBER,  results  of  nerve  suture,  735 
Huguier,  colotomy  for  imperforate  anus,  90 
HuLKE,  wound  of  the  obturator  artery,  42 
Hume,  nephrectomy,  155 

Humphry,  case  of  encysted  vesical  calculus,  392 
Hunter,  method  of  treating  urethral  stricture,  428 
Hutchinson,  fatal  case  of  lithotomy,  408 
HiJTER,  excision  of  the  hip,  599 

Israel,  ureteritis,  120;  renal  sarcoma,  143  ;  partial  nephrectomy,  162 

Jalaguier,  septic  peritonitis.  218 

James,  ligature  of  the  abdominal  aorta,  31 

Jellett,  drainage  after  ovariotomy,  534 

Jerosch,  hydatid  disease  of  the  kidney,  146 

Jessett,  intussusception,  183;  intestinal  anastomosis  with  Senn's  plates,  273;   two 

cases  of  jejunostomy  for  oesophageal  cancer,  340 
Jessop,  lumbar  colotomy,  99  ;  forceps  for  bladder  growths,  390 
Jonas,  operation  for  talipes,  709 
Jones  (R.),  acute  intestinal  obstruction,  175  ;   arthrodesis  for  infantile  paralysis,  638  ; 

operation  for  talipes,  708 
Jones  (T.),  nephro-lithotomy,  124 
Jordan  (Furneaux),  amputation  at   the   hip-joint,  578,  584,  585  ;   excision  of   the 

ankle,  698 

Kaiser,  septic  peritonitis,  216 

Kammerer,  enterorraphy,  240;  results  of  gastro-jejunostomy,  339 

Karewsky,  pancreatic  cysts,  371 

Kast,  collateral  circulation  after  ligature  of  abdominal  aorta,  30 

Keegan,  perinatal  lithotrity,  421 ;  litholapaxy  in  male  children,  421,  423  ;  litholapaxy 
in  the  female,  427 

Keen,  ligature  of  the  abdominal  aorta,  32  ;  aneurysm  of  the  renal  artery,  146 ;  per- 
foration of  typhoid  ulcers,  211  ;  Murphy's  button,  238;  case  of  gunshot  wound  of 
the  abdomen,  285 ;  gastrostomy  by  Witzel's  method,  301 ;  removal  of  portions  of 
the  liver  for  tumours,  351  ;  air  distension  in  diagnosis  of  ruptured  bladder,  430; 


INDEX  OF  XAMi:S.  76 1 

results  of  excision  of  the  rectum,  500;  colotomy  before  excision  of  the  rectum.  501; 
excision  of  the  rectum,  513 

Keetley,  abdominal  section  for  hernia,  53;  radical  cure  of  umbilical  hernia,  83; 
multiple  renal  calculi,  132;  partial  nephrectomy,  162 

Kellock,  modification  of  Phelps'  operation,  709 

Kelly,  encapsuled  ovarian  cysts,  536;  oophoritis,  542;  removal  of  the  uterine  ap- 
pendages, 543,  545 ;  conservative  surgery  of  the  uterine  appendages,  548 ;  pain 
associated  with  uterine  myomata,  551  ;  supra-vaginal  hysterectomy,  557  ;  mortality 
of  abdominal  hysterectomy.  558 ;  indications  for  vaginal  hysterectomy,  562 ; 
Caesarian  section,  571  ;  Porro's  operation,  573,  574 

Kelsey,  excision  of  the  rectum.  506 

Kexdirdjy,  ligature  of  internal  iliac,  20 

Key,  strangulated  hernia.  41 

Keyes,  tamponnadc  of  bladder  for  haemorrhage,  382;  lithotrity.  416;  treatment  of 
vesical  calculus  in  the  female.  424 

KiRKHAM.  ureteral  calculus.  167 

KiRJiissox,  wounds  of  the  femoral  artery.  60S;  ligature  of  the  common  femoral 
artery,  610 

Kocher,  method  of  radical  cure  of  hernia,  77 ;  radical  cure  of  femoral  hernia,  79 ; 
intestinal  clamp,  259 ;  enterectomy,  265  ;  indications  for  operation  in  gastric 
hasmorrhage,  309  ;  mortality  of  pylorectomy,  315  ;  pylorectomy,  316 — 320;  modifi- 
cation of  gastro-jejunostomy.  337 ;  carcinoma  of  the  testis,  477 

KuNiG,  nephrectomy.  14S  ;  incision  for  nephrectomy,  156;  enterorraphy.  241 

KORTE,  gastrotomy  for  hiemorrhage,  308 

KOUGH,  case  of  strangulated  hernia,  39 

Kramer,  peritonasum  in  supra-pubic  lithotomy,  40G 

Keaske,  excision  of  the  rectum,  498 — 513 

Kummell,  intestinal  obstruction,  176 

KussMAUL,  thrombosis  of  mesenteric  vessels.  187 

Kvster,  stricture  of  ureter,  170;  gastrotomy  for  haemorrhage,  308  ;  liEemorrhage  after 
cholecystenterostomy,  367  ;  classification  of  vesical  growths,  375 

LABBfe,  gastrotomy  for  a  foreign  body,  306 

Landon,  inguinal  colotomy,  108 

Lane,   case   of   ureteral   calculus,    168;     intestinal   obstruction   by  gall-stones,    186; 

enterectomy,  258,  264  ;  intestinal  clamp.  260  ;  treatment  of  ununited  fracture,  631  ; 

use  of  screws  for  fractures.  679  ;  operative  treatment  of  simple  fractures,  682 ; 

erasion  of  the  ankle,  701 ;  modification  of  Phelps' operation,  709 ;  operation  for 

talipes,  710 
Laxge,  nephrectony,  149,  15S  ;  suture  of  the  femoral  vein,  608 
Langenbeck.  gunshot  injuries  of  the  hip-joint.  595  ;  case  of  wound  of  the   femoral 

vein,  609 
LANGENBrCH,  incision  for  nephrectomy,  152 
Laxgton.  hernia  in  children.  57 
Laplace,  forceps  for  enterorraphy,  etc.,  249,  333 

Lawrence  (Sir  AV.),  strangulated  hernia,  41 ;  wound  of  the  obturator  artery.  42 
Lawrie,  membranous  colitis.  90 
Le  Dentu,  case  of  papillomata  of  the  ureter,  146 
Lee  (H.).  sepsis  after   operation  for  varicocele,  475 ;   late  results  of  excision  of  the 

knee,  636 
Lees  (D.  1>.),  appendicitis,  199 

Leonard,  ligature  of  external  iliac  for  elephantiasis,  3 
Leopold,  nephrectomy,  150 

LETlfcVANT,  autoplastic  flaps  in  nerve  suture,  737 
Leube,  indications  for  operation  in  gastric  haemorrhage,  309 
Levis,  injection  of  carbolic  for  hydrocele,  465  ;   suppuration  after  carbolic  injection, 

466 
Lewis,  ectopia  vesicae,  448 

LiDDBLL,  ligature  of  common  iliac,  16 ;  ligature  of  internal  iliac,  19 
Lindner,  partial  resection  of  the  intestine,  263 
LiNHART,  case  of  wound  of  the  femoral  vein,  609 
LiSFRANC,  amputation  through  the  tarso-metatarsal  joints,  717 
Lister  (Lord),  operation  for  varicocele,  472;  Garden's  amputation,  625;   excision  of 

the  knee,  634  ;  treatment  of  fractured  patella  by  wiring,  652  ;  removal  of  loose 

bodies  from  the  knee-joint,  656 
LiSTON,  ligature  of  the  common  iliac,  13  ;  case  of  pistol-shot  wound  of  the  groin,  607 
Little,  ligature  of  femoral  artery  for  acute  inflammation  of  the  knee-joint.  613 
LiTTLEWOOD,  modification  of  Scnn's  plates,  275 
LiTTRk,  colotomy,  85 


762  IXDEX  OF  NA]\IES. 

Lloyd  (Jordan),  tenderness  due  to  renal  calculus,  115;  method  of  controlling 
hasmorrhage  in  amputation  at  the  hip-joint,  579,  584 

LoCKWOOD,  radical  cure  of  hernia.  59  ;  radical  cure  of  femoral  hernia,  80,  81  ;  lumbar 
colotomy,  99 ;  distension  ulcers  of  the  CEecum,  loi  ;  appendicitis,  198,  201  ;  per- 
forating duodenal  ulcer,  210;  septic  peritonitis,  214,  215;  Seun's  plates,  249; 
enterorraphy,  253  ;  enterectomy,  265  ;  operation  for  hydrocele,  471 ;  case  of  removal 
of  semilunar  cartilage,  659 

LoNGiiOBE  (Sir  T.),  gunshot  wounds  of  the  hip-joint.  596;  gunshot  injuries  of  the 
knee-joint,  639 

LOEETA,  introduction  of  wire  into  an  aneurysmal  sac,  32  ;  gastrotomy  for  dilatation  of 
a  stricture  of  the  oesophagus,  304;  dilatation  of  the  pylorus,  310 

LowsoK,  resection  of  the  csecum,  261 

Lucas  (E.  C),  strangulated  umbilical  hernia,  51:  case  of  calculous  anuria,  137  ; 
nephrectomy,  151 ;  nephrorraphy,  165 

LucAS-CHAMPOXNii:EE,  radical  cure  of  umbilical  hernia.  83 

LrCKE,  case  of  fat  embolism.  649 

Lund,  recto-vesical  fistula,  89;  inflator  for  the  colon.  96;  fistula  in  ano,  487;  astra- 
galectomy,  711 

Mac  Corhac,  ligature  of  the  gluteal  artery,  27;   gunshot  wounds  of  the  abdomen, 

291;  cases  of  ruptured  bladder,  429;  suture  of  the  bladder  after  rupture,  431; 

ligature  of  the  popliteal  artery,  661,  662 ;  steps  of  Pasquier  Le  Fort's  amputation, 

695  ;  case  of  Mickulicz's  operation,  706 
McDouGALL,  appendicitis.  1S9 
Macdonald,  results  of  pylorectomy,  315 
Macewex.  acupuncture  in  the  treatment  of  aneurysm,  32 ;   method  of  radical  cure  of 

hernia.  64 ;  method  of  compression  of  the  aorta,  580 ;  suppuration  after  wiring  a 

fractured  patella,  654 ;  cases  of  fractured  patella,  656 ;  osteotomy  of  the  femur, 

725  ;  laminectomy,  748 
Maclagax,  intestinal  obstruction  by  gall-stones,  186 
Maclaeex,  perforating  gastric  ulcer.  207;  septic  peritonitis,  217 
MACLEOD,  excision  of  the  rectum.  503  ;  heemorrhage  after  excision  of  the  rectum,  516  ; 

Syme's  amputation.  689  ;  objections  to  Pirogoff's  amputation,  691 
Macnamaea.  ligature  of  the  common  femoral  artery,  611 
Maceeady.  radical  cure  of  hernia,  54 

MADELtrxG.  modification  of  inguinal  colotomy.  108  ;  intestinal  obstruction,  176 
Magill.  vegetable  plates  for  enterorraphy,  248 
Maisoxxeuve.  internal  urethrotomy,  445 
Makixs.  ligature  of  iliac  arteries  by  abdominal  section,  22 ;  intestinal  clamps,  259  ; 

closure  of  an  artificial  anus,  279;   ectopia  vesicae,  450;  operation  for  hypospadias, 

453  ;  arthrectomy  for  sacro-iliac  disease.  577 
Malcolm,  renal  sarcoma.  144  ;  abdominal  nephrectomy,  156 
Mapothee,  ilio-femoral  aneurysm  cured  by  pressure.  2 
Mabsh.  nephrectomy,  147;  acute  intestinal  obstruction.  180;  indications  for  excision 

of  the  hip,  590  ;  necrosis  in  hip  disease,  592  ;  method  of  fixing  the  bones  after  knee 

excision,  646;  case  of  needle  point  in  the  knee-joint,  656;  internal  derangements 

of  the  knee,  658 
Maeshall.  nerve  stretching,  741 

Maewedel.  method  of  performing  gastrostom3\  300.  303 
Mason',  cocaine  ansesthesia  for  strangulated  hernia,  ^^ 
Maubeac,  wound  of  the  femoral  vein,  608 

Mauxdee,  ligature  of  the  femoral  for  acute  arthritis  of  the  knee,  613 
Maunsell.  method  of  performing  enterorraphy,  233.  234 ;  enterectomy,  259 
May,  lumbar  colotomy,  99;  nephro-lithotomy,  129 

Maydl,  mortality  after  pylorectomy,  315  :  operation  for  ectopia  vesicae,  447,  451 
McAedle.  puncture  of  the  kidney,  164;  statistics  of  cancer  of  the  stomach,  315 
McBuENEY,  method  of  radical  cure  of  hernia,  78 ;  appendicitis,  194,  201 ;  incision  of 

the  duodenum  in  choledochotomv.  364 ;  method  of  compressing  the  common  iliac, 

583 

McCaethy,  thrombosis  of  the  mesenteric  veins,  187 

McCosH,  treatment  of  septic  peritonitis,  217,  219  ;  enterorraphy,  253  ;  enterectomy, 
262  ;  mortality  after  excision  of  the  rectum,  499 

McGiLL.  radical  cure  of  umbilical  hernia,  83  ;  Meckel's  diverticulum,  the  cause  of 
acute  intestinal  obstruction,  179  ;  partial  prostatectomy,  388,  389 

McGeaw,  Murphy's  button,  238;  gunshot  wounds  of  the  abdomen,  288;  case  of  gun- 
shot wound  of  the  abdomen.  291 ;  splenectomy,  343;  choledochotomy,  364 

Meade,  case  of  carcinoma  of  the  testis,  477 

Meyeb  (W.).  ligature  of  internal  iliac  for  enlarged  prostate,  20;  appendicitis,  203; 
gastrostomy,  300 


INDEX  OF  NAMES.  763 

MiCKULicz,  intussusception,  184;  treatment  of  septic  peritonitis.  213;  abdominal 
hasmorrhage.  218  ;  enterectomy.  262 ;  gastrotomy  for  hasmorrhage,  308  ;  pyloro- 
plasty, 312  ;  gauze  packing  after  splenectomy,  345  ;  operation  for  prolapse  of  the 
rectum,  497 ;  tarsectomj',  706 

Miles  (A.  B.).  cases  of  gunshot  wound  of  the  abdomen,  291 

Miller,  gluteal  aneurysm,  28 ;  amputation  of  the  penis,  462 

MiLTOX,  case  of  lithotrity  for  large  stone,  409;  lithotrity,  411 

Mitchell  0^'kir).  removal  of  uterine  appendages  for  epilepsy,  543 

MoEEAU.  semilunar  incision  for  excision  of  the  knee,  642 

MoRiSAXi.  enterectomy.  232 

MoRisox.  successful  case  of  pyloroplasty,  314  ;  incision  for  exploration  of  the  bile 
ducts.  354  ;  drainage  after  choledochotomy,  363 

Morris,  distension  ulcers  of  the  caecum,  loi ;  renal  pain,  115;  renal  calculus,  118, 
119,  122;  nephro-lithotomy,  125,  126,  129;  partial  nephrectomy,  158;  results  of 
nephrectomy.  162;  ureteral  calculus,  168;  stricture  of  the  ureter,  170;  cancer  of 
the  pylorus.  316;  recurrence  of  hydrocele,  468 

Morrison  (J.  R.).  perforated  gastric  ulcer,  206 

MoRRiss,  appendicitis.  192 

MoRTOX,  gunshot  wounds  of  the  rectum  and  diaphragm.  286  ;  secondary  haemorrhage 
after  removal  of  vesical  growths.  385  ;  air  distension  in  ruptured  bladder,  430 ; 
injection  of  iodine  for  spina  bifida,  742 

MoRTOX  (T.  S.  K.).  table  of  cases  of  gunshot  wounds  of  the  abdomen,  291 

MOTT,  incision  for  tying  the  common  iliac,  16 

MouLLix.  renal  pain.  121;  nephro-lithotomy,  126;  prostatectomy,  388;  internal 
derangements  of  the  knee,  658 ;  case  of  nerve  grafting,  739 

Mouloxguet.  excision  of  the  rectum,  513 

MuxRO.  thrombosis  of  the  mesenteric  vessels,  187 

MuRCHisox,  gall-stones,  122 

Murphy  (J.  B.),  button  for  intestinal  operations,  236;  indications  for  gastro-jejunos- 
tomy,  327;  gastro-jejunostomy.  330;  drainage  tube  button  for  cholecj'Stostomj'-, 
357;  cholecystenterostomy,  364;  poisoning  after  injection  of  a  hydrocele  with 
carbolic.  467 

Myers  (T.  H.),  operation  for  congenital  dislocation  of  the  hip,  605 

Myxtee,  stricture  of  the  ureter,  170 ;  appendicitis,  192,  200 

Xaxcrede,  nephrectomy.  145 ;  operation  in  gunshot  wounds  of  the  abdomen,  283 

Xewmax.  nephrorraphy.  164 

XlCHOL,  method  of  performing  prostatectomy.  389 

Xove-Jasseraxd,  results  of  Maydl's  operation  for  ectopia  vesicae,  448 

O'CoxoR,  results  of  radical  cure  of  hernia,  77  ;  appendicitis,  198 

Ollier.  amputation  at  the  hip-joint,  57S ;  mode  of  growth  of  the  femur,  594 ;  excision 
of  the  knee.  642,  647 

Olshausex.  vaginal  hysterectomy.  569 

Otis,  ligature  of  external  iliac.  3 ;  ligature  of  common  iliac.  12  ;  ligature  of  internal 
iliac,  19;  internal  urethrotomy.  444;  gunshot  wounds  of  the  hip-joint,  595;  liga- 
ture of  the  femoral  for  gunshot  injuries.  608  ;  gunshot  injui'ies  of  the  ankle.  698 

OWEX,  case  of  hydatid  cyst  of  the  liver.  351;  fatal  rupture  of  the  bladder  during 
litholapaxy,  423  ;  erasion  of  the  knee,  649  ;  Phelps'  operation  for  talipes,  709 

Packard,  ligature  of  the  common  iliac,  11 

Page  (F.).  nephro-lithotomy,  136;  wound  of  peritonaeum  in  lumbar  nephrectomy,  151  ; 

abdominal    nephrectomy,    157;    rupture   of   the  ureter,    170;    successful  case  of 

pyloroplasty,  314;  case  of  traumatic  aneurysm  of  the  leg,  668 
Page  (H.  W.).  case  of  gastro-jejunostomy,  328 
Paget  (Sir  J.),  symptoms  of   strangulated   hernia.  34;   condition  of   the   bowel   in 

strangulated  hernia,  40;  strangulated  umbilical  hernia,  49;  shock  after  lithotomy, 

408 
Parker,  enterectomy,  265 ;  suture  of  the  bladder  after  supra-pubic  lithotomy.  404  ; 

imperforate  anus.  517;  excision  of  the  hip.  599;  syndesmotomy,  731 
Parkes,  bullet  wound  of  the  kidney,  145  ;  amount  of  damage  in  gunshot  wound  of  the 

abdomen,  282  ;  haemorrhage  from  ruptured  intestine,  293 
Parkill.  clamp  for  use  in  ununited  fractures,  631 
Parkix,  calculous  anuria.  137 

Paoli.  partial  nephrectomy,  158;  implantation  of  the  ureter  into  the  bladder,  172 
Pasquier  Le  Fort,  modification  of  Pirogoff's  amputation,  694 
Paul,  tubes  for  drainage  of  the  intestine,  107;  enterostomy.  226;  decalcified  bone 

tubes  for  enterorraphy,  246;  colectomy  in  two  stages,  257;  mortality  of  excision 


764  INDEX  OF  NAMES. 

of  the  rectum,  499;  excision  of  the  rectum,  512;  truss  for  use  after  excision  of 

the  rectum,  517 ;  splint  for  excision  of  the  ankle,  698 
Paulick,  case  of  complete  extirpation  of  the  bladder,  384 
Peau,  case  of  gastrotomy  for  a  foreign  body,  306 
Penrose,  implantation  of  the  ureter  into  the  bladder,  172 
Pepper,  lumbar  colotomy,  100  :  perforated  gastric  ulcer,  208 
Perry,  septic  peritonitis,  215 

Phelps,  tenotomy  for  contracted  knee.  648  ;  operation  for  talipes,  709 
Pick,  amputation  through  the  knee-joint,  633 ;  scar  tissue  used  to  unite  ends  of  a 

divided  nerve,  737 
PiLCHER,  supra-pubic  lithotomy,  404;  wounds  of  the  femoral  artery,  608;  wound  of 

the  femoral  vein.  609 
PiLLORi:,  colotomy,  85 

PiNNOCK,  ligature  of  the  femoral  for  elephantiasis.  3 
PiROGOFF,  collateral  circulation  after  ligature  of  the  abdominal  aorta,  30  ;  amputation 

of  the  foot,  691 
Pitt,  case  of  perforated  gastric  ulcer,  208;   case  of  pancreatic  cyst,  370;    tumour  in  a 

case  of  acute  pancreatitis.  373 
Pitts,  splenectomy  for  injury,  342 
PoGGi.  ectopia  vesicse,  447 

Poland,  suppression  of  urine,  140;  amputation  through  the  thigh,  623 
Pollard,  suture  of  the  bladder  after  supra-pubic  lithotomy,  404 
Pollock,  recurrence  of  hydrocele  after  operation,  468  ;  treatment  of  hseraorrhoids  by 

crushing,  492  ;  amputation  through  the  knee-joint,  633 
Porter,  ligature  of  the  common  femoral.  611 ;  excision  of  the  ankle,  699 
Posadas,  enucleation  of  hydatids  of  the  liver.  349 
Powers,  treatment  of  fractured  patella  by  wiring,  652 
Putnam,  laminectomy  for  spinal  tumour,  749 
Pye  Smith  (R,  J.),  obstruction  by  Meckel's  diverticulum,  179;  perforating  duodenal 

ulcer,  211 

Qup^NU,  case   of   gastro-jejunostomy,  331 ;    excision  of   the   rectum,  501 ;    abdomino- 
perinjeal  excision  of  the  rectum,  515 

Eake,  nerve  stretching  for  perforating  ulcer  due  to  leprosy,  740 

Ralfb,  solvent  treatment  of   renal  calculus,  117;   duodenal   ulcer   simulating   renal 

calculus,  121 
Ramm.  castration  for  enlarged  prostate.  479 
Ramdohr,  enterectomy,  265 
Ramsey,  renal  tuberculosis,  113  ;  nephrectomy,  154  ;  partial  nephrectomy,  158;  case  of 

pancreatic  cyst,  372 
Rand,  appendicitis,  203 

Ransohoff,  enterorraphy,  254  ;  enterectomy,  262 
Rawdon,  ruptured  kidney.  143  ;  case  of  pylorectomy,  325 
Redard,  results  of  operation  for  congenital  dislocation  of  the  hip,  606 
Reed,  nerve  anastomosis,  738 
Rees,  renal  calculus.  115 
Reeves,  excision  of  fistula  in  ano,  489 
Regnier,  tuberculosis  of  the  ureter,  154 
Rehn,    sacral   resection    in    excision    of    the  rectum,    510  ;    vaginal   excision   of    the 

rectum,  514 
Reichel,  enterectomy,  262 
Reynolds,  treatment  of  hip  disease,  591 
Richardson,   gastrotomy  for  foreign    body   in    the    oesophagus,    307  ;  recurrence   of 

pancreatic  cyst  after  drainage,  372 
Richmond,  ureteral  calculus.  169 

RiCKARD.  cholangitis  after  cholecystenterostomy.  366 
Ricketts.  enterorraphy,  235  ;  enterectomy,  257 
RiDLON,  treatment  of  talipes.  708 
RiEDEL,  enterectomy,  262 

Rindfleisch,  malignant  disease  of  the  testis  following  injury,  479 
RiviNGTON,  gangrene  after  ligature  of  external  iliac,  8  ;  rupture  of  the  bladder,  429 
RizzoLi,  operation  for  imperforate  anus,  518 
Roberts,  experiments  on  the  solubility  of  calculi,  117 
Robinson,  enterorraphy,  253 
ROBSON,  colotomy  for  colitis,  90  ;    inguinal  colotomy,  106  ;   delcalcified  bone  bobbin, 

240;    ruptured  intestine,  292;    pylorectomy  in  two  stages,  314;    bone  bobbin  in 

pyloroplasty,  314  ;    mortality  of  pylorectomy,  315  ;    mortality  of  gastrectomy,  326  ; 

bone  bobbins  for  gastro-jejunostomy,  332  ;    gastroplication,  339  ;    calculi  in   the 


INDEX  OF  NAMES.  765 

common  bile  duct,  353  ;  operation  for  biliary  calculi,  354 ;  difficulties  in  cho- 
lecystostomy,  355;  cholelithotrity,  359;  digital  exploration  of  the  bile  ducts, 
360  ;  incision  of  the  duodenum  in  choledochotomy,  364  ;  indications  for  cholecys- 
tectomy, 368;  posterior  incision  for  acute  pancreatitis.  374;  operation  for 
ectopia  vesicae,  449 ;  use  of  gold  wire  for  fractured  patella.  655  ;  nerve  grafting, 
738  ;   excision  of  spina  bifida.  744 

RODMAX,  tubage  for  oesophageal  stricture,  297 

RoEESCH,  tubercular  peritonitis,  219 

ROGEK,  enterectomy,  232 

Ross,  case  of  choledochotomy,  363 

Roux.  cases  of  gastrotomy  for  hfemorrhage,  308  ;  case  of  wound  of  the  femoral  vein,  609 

Russell,  operation  for  hypospadias.  453 

RUTHEEFOED.  ruptured  urethra,  435 

Rydygiee.  enterectomy,  265  ;  sacral  resection  in  excision  of  the  rectum.  510;  excision 
of  the  rectum,  513 

Sachs,  partial  resection  of  intestine,  263 

Saxgeb,  ureteral  calculus.  169 

Sayee.  paralysis  due  to  phimosis,  456 

SCHACKXEE.  gunshot  wounds  of  the  mesentery,  285 

8CHEDE,  catheterisation  of  the  ureter.  383  ;  suture  of  the  femoral  vein,  608 

SCHLEICH,  production  of  local  anaesthesia,  175 

Schmidt,  renal  sarcoma,  143 

SfeDiLLOT.  modification  of  PirogoflPs  amputation.  694 

Sexx,  acute  intestinal  obstruction,  177;  intussusception.  182,  184;  volvulus,  186; 
inflation  of  the  intestine  with  hydrogen,  188 ;  enterorraphy,  239 ;  bone  plates  for 
intestinal  operations,  242,  248:  omental  grafting.  267;  intestinal  anastomosis, 
268,  271 ;  excision  of  the  caecum,  274 ;  treatment  of  pancreatic  cysts,  370 ;  excision 
of  the  rectum,  509 ;  bone  cylinders  for  ununited  fractures,  631 

Shaw  (L.  E.),  case  of  perforated  gastric  ulcer,  206 

Sheex.  ligature  of  external  iliac,  5 

Shepheed,  nephro-lithotomy,  134;  haemorrhage  after  cholecystenterostomy,  367; 
ligature  of  anterior  tibial,  668 

Shield,  perforated  duodenal  ulcer,  210;  case  of  ulceration  of  the  femoral  vessels  by 
a  bubo.  610 ;  erasion  of  the  knee-joint,  649 

Shutee,  case  of  amputation  at  the  hip-joint.  579 

SiLCOCK.  volvulus,  185  ;  perforated  gastric  ulcer,  208 

Simon,  valvular  obstruction  of  the  ureter,  169 

Sinclair,  vaginal  hysterectomy.  564.  569 

SiPPY,  splenectomy  for  splenic  anaemia.  343 

Skey.  ligature  of  the  common  iliac.  18 ;  Chopart's  amputation,  715 ;  amputation 
through  the  tarso-metatarsal  joints,  717 

Smith  (Geeig),  lumbar  colotomy,  94 ;  nephrectomy,  147.  149,  156 ;  acute  intestinal 
obstruction,  177 ;  intussusception.  183 ;  volvulus.  185 ;  septic  peritonitis,  214 ; 
enterostomy,  222;  enterectomy,  232;  closure  of  faecal  fistula,  277;  peritonitis  in 
gunshot  wounds  of  the  abdomen.  283  ;  splenectomy,  344 ;  hepatic  abscess,  350 ; 
preparatory  treatment  of  ectopia  vesicae,  449  ;  opium  after  ovariotomy,  539  ;  con- 
servative surgery  of  the  uterine  appendages.  548,  549 

Smith  (H.),  clamp  and  cautery  operation  for  haemorrhoids,  491 

Smith  (.Johnson),  cases  of  Syme's  amputation,  689 

Smith  (Stephen),  ligature  of  common  iliac,  11;  wounds  of  the  common  iliac.  12; 
amputation  through  the  knee-joint,  632 

Smith  (T.),  nephro-lithotomy,  136;  intestinal  obstruction  by  gall-stones,  186;  supra- 
pubic aspiration.  432 

Smyly.  ligature  of  the  common  femoral,  611 

Smythe.  nephro-lithotomy,  131 

SoNNENBEBG,  the  peritonaeum  in  supra-pubic  lithotomy,  406 

South,  strangulated  hernia.  46 

Southam.  ruptured  femoral  aneurysm,  2  ;  appendicitis.  202  ;  case  of  cancer  of  the 
pylorus,  315  ;  pylorectomy,  316  ;'case  of  pylorectomy.  322  ;  recurrence  of  hydrocele 
after  carbolic  injection.  466 

Spanton.  method  of  radical  cure  of  hernia,  6r 

Spencer,  gunshot  wounds  of  the  abdomen,  283  ;  operation  for  traumatic  dislocation  of 
the  hip,  604 

Stanley,  incision  for  ligature  of  the  common  iliac,  16  ;  rupture  of  the  ureter,  170 

Stavely.  volvulus,  185 

Stevens,  ligature  of  internal  iliac,  21 

Stevenson,  nephro-lithotomy,  131 

Stimson,  supra-vaginal  hysterectomy,  555 ;  subastragaloid  amputation.  695 


^66  INDEX  OF  NAMES. 

Stokes,  amputation  above  the  knee,  627 

Stonham,  cases  of  gastrostomy  for  cancer  of  the  tongue,  296 

Sutton,  perforated  typhoid  ulcer.  212;  malignant  ovarian  tumours.  527 ;  ovariotomy, 

536  ;  removal  of  the  uterine  appendages,  542 
Swain,  perforated  gastric  ulcer,  205  ;  two  fatal  cases  of  digital  dilatation  of  the  pylorus, 

312 
Syme.  ligature  of  common   iliac,    11;    ligature   of   the   gluteal   artery.  27;     external 

urethrotomy.  437,  443 
Symosds,  nephro-lithotomy,  126;  short  tubes  for  oesophageal  stricture,  297 

Tait.  abdominal  section  for  hernia,  53 ;  intestinal  obstruction  by  gall-stones,  187  ; 
cholelithotrity,  358 ;  removal  of  the  uterine  appendages.  544  ;  Porro's  operation, 

573 

Taylor  (F.).  intussusception,  181 

Taylor  (E.  H.).  excision  of  the  rectum,  501 

Teale,  amputation  through  the  thigh,  624  ;  case  of  fractured  patella,  654  ;  amputa- 
tion through  the  leg.  674 

Terrier,  radical  cure  of  hernia,  55 ;  condition  of  gall-bladder  in  obstruction  of  the 
common  duct,  353 

Thayer,  tumour  in  acute  pancreatitis,  373 

Thomas  (Thelwell),  operation  for  hEemorrhoids,  494 

Thomas  (W.  T.),  case  of  ruptured  intestine,  295 

Thompson,  htematuria  from  tumour  of  the  bladder,  376 ;  forceps  for  growths  of  the 
bladder,  380  ;  abscess  after  removal  of  growths  of  the  bladder,  385 ;  lateral  litho- 
tomy, 396;  rectal  distension  in  supra-pubic  lithotomy,  401;  lithotrity,  411;  re- 
currence after  lithotrity,  412 ;  form  of  lithotrite.  415  ;  evacuation  in  lithotrity, 
417;  treatment  of  vesical  calculus  in  the  female.  424  ;  internal  urethrotomy,  444  ; 
urethrotome,  446 

Thomson,  perforated  typhoid  ulcer,  212 

Thorburn.  laminectomy   for  injury,  747 ;    laminectomy   for  perforating  wounds,  748 

Thornton,  nephro-lithotomy,  134,  136:  nephrectomy,  146;  abdominal  nephrectomy, 
154.  158;  ureteral  calculus,  169;  gastrotomy  for  foreign  body.  306;  successful 
case  of  splenectomy,  342  ;  danger  in  puncturing  hepatic  abscess,  350 ;  cavity  in 
the  liver  containing  biliary  calculi,  355  ;  ovariotomy,  529 ;  treatment  of  hjemor- 
rhage  in  ovariotomy,  531  ;  encapsuled  ovarian  cysts,  535  ;  treatment  of  papillary 
ovarian  cysts,  536  ;  supra-vaginal  hysterectomy,  552, 555  ;  mortality  after  hysterec- 
tomy, 558 

TiRARD,  intestinal  adhesions,  121 

TizzONi,  ectopia  vesica.  447 

Travers,  strangulated  hernia.  41 

Trendelenberg,  operation  for  ectopia  vesicse,  450;  excision  of  the  rectum  through 
the  abdomen,  515 

Treves,  ligature  of  internal  iliac  by  abdominal  section,  25  ;  artificial  anus  in  the 
CEecum.  112  ;  acute  intestinal  obstruction,  173,  177,  179;  strangulation  through  the 
foramen  of  AVinslow,  180;  volvulus,  183;  intestinal  obstruction  by  gall-stones, 
186 ;  appendicitis  with  abscess,  195 ;  relapsing  appendicitis,  200,  201  ;  appendix 
in  a  hernial  sac,  203  ;  septic  peritonitis,  214,  216;  enterorraphy,  255  ;  enterectomy, 
261  ;  intestinal  anastomosis,  272  ;  Mauser  bullet  wounds  of  the  abdomen,  283 ; 
Loreta's  operation.  311;  treatment  of  ununited  fracture  of  the  femur,  630; 
Chopart's  amputation,  714 

Tripier,  modification  of  Chopart's  amputation,  715 

Tuffier,  partial  nephrectomy,  158;  ureteral  calculus,  167,  169;  case  of  complete 
extirpation  of  the  bladder,  384  ;  spinal  anaesthesia,  753 

Tupolske,  pylorectomy  in  two  stages,  314 

Turner,  volvulus,  185  ;  case  of  fractured  patella  treated  by  wiring,  655 

Tyrrell,  accident  in  lateral  lithotomy,  397 

Tyson,  appendicitis,  194 

Van  Arsdale,  septic  peritonitis,  218 

Van  Hook,  uretero-ureterostomy,  171 

Yanlair,  bone  tubes  for  use  in  nerve  sutiire,  737 

Velpeau,  wound  of  external  iliac.  3 

Verneuil,  amputation  at  the  hip-joint,  579 

YoGT,  case  of  fat  embolism.  649 

YOLKMANN,  supra-pubic  route  for  removal  of  growth  of  the  bladder,  378;  results^  of 

excision  of  the  rectum,  500  ;  excision  of  the  rectum,  506 ;  trans-patellar  excision 

of  the  knee.  642  ;  shock  after  excision  of  the  knee,  649 
YoN  Antal,  supra-pubic  route  for  removal  of  growth  of  the  bladder,  378 
YoN  Baracz,  vegetable  plates  for  enterorraphy,  248 


INDEX   01"  NAMES.  -j^J 

Von  Dittel,  method  of  prostatectomy,  389 

Von  Hacker,  modification  of  gastro-jejunostomy,  336 

Wagstaffe.  advantages  of  Tripier's  amputation,  716 

Walker  (G.)-  renal  sarcoma,  143,  144 

Walker  (J.  W.),  resection  of  ileum  for  gunshot  wound,  290 

Wallace,  growths  of  the  bladder.  377 

Walsham,  vesical  calculus  in  female  children,  426 ;  case  of  ruptured  bladder.  429 ; 

ligature  of  femoral  artery,  6ig ;  age  for  cuneiform  tarsectomy,  712 
Walter,  perforated  gastric  ulcer,  204  ;  enterectomy.  265 
Walters,  lumbar  colotomy,  98 
Warbasse,  ectopia  vesic<B,  447 
Ward,  case  of  fractured  patella,  655 

Warren,  splenectomy,  343  ;  laminectomy  for  tumour  of  the  spinal  cord,  749 
Washbourx,  detection  of  tubercle  bacilli  in  the  urine,  119 
Waterman,  treatment  of  hip  disease,  591 
Watson,  speculum  for  the  bladder,  379;  prostatectomy,  388;  modification  of  Pirogoff's 

amputation,  694  ;  tarsectomy,  706 
Weill,  mortality  after  hysterectomy,  558 
Weir,  nephrectomy,   151;  enterectomy,  256;    results  of   treatment  of   hydrocele   by 

carbolic  injection,  466 
Wells,  abdominal  nephrectomy.  156 ;  lateral  lithotomy.  396 
West,  granular  kidney.  120  ;  septic  peritonitis,  213 
Wheelhouse,  iliac  aneurysm,  i;  external  urethrotomy.  433.  437,  438;  castration  in 

epithelioma  of  the  penis,  463 ;  case  of  fractured  patella,  654 
Wherry,  ligature  of  internal  iliac  by  abdominal  section,  25 
Whipham,  renal  calculus,  133 
White,  ligature  of  external  iliac  for  elephantiasis,  3  ;  prostatectomy.  388 ;  castration 

for  enlarged  prostate,  479;  laminectomy  for  fractured  spine,  748 
Whitehead,   case   of   gastrostomy   for   cancer    of    the   tongue,   296;    operation   for 

haemorrhoids,  493 
Wiggins,  case  of  ruptured  intestine,  233,  294 
WiLLEMS,  excision  of  the  rectum,  513 
Willett,  sudden  death  from  puncture  of  an  abdominal  tumour,  347 ;  cholecystenter- 

ostomy,  365  ;  case  of  ruptured  bladder,  430 
Williams,  indications  for  removal  of  the  uterine  appendages,  539 
Wilson,  case  of  multiple  gunshot  wounds  of  the  ileum,  290 
Winiwarter,  frequency  of  adhesions  in  cancer  of  the  pylorus,  315 
WiTZEL,  method  of  gastrostomy,  300  ;  excision  of  the  rectum,  513 
WuLFLER.  modification  of  gastro-jejunostomy,  337 
Wood,  strangulated  umbilical  hernia,  49  ;  operation  for  ectopia  vesicas.  447  ;  castration 

for  enlarged  prostate,  480  ;  vasectomy,  486 
Woolsey,  prostatectomy,  388 
Wright,  renal  calculus,  114;  gall-stones  simulating  renal  calculus,  122;  haemorrhage 

after  splenectomy,  345  ;  indications  for  hip  excision,  590 ;  condition  of  the  limb 

after  hip  excision,  594  ;  fracture  of  the  femur  during  hip  excision,  597 ;  excision 

of  the  hip,  600;  excision  of  the  knee  for  infantile  paralysis,  638;  erasion  of  the 

knee,  649,  651 ;  erasion  of  the  ankle,  700;  excision  of  the  astragalus,  703,  711 
Wyeth,  bloodless  method  of  amputation  at  the  hip-joint,  581 

Yelloly,  case  of  vesical  calculus  in  the  female,  423 

Zeidler,  enterectomy,  262 


GENERAL    INDEX. 


VOLUME    II. 


Abbe's  modification  of  Kader's  method  of 

gastrostomy,  303 
Abdominal  aneurysm,  treatment  of,  29 

Acupuncture,  32 

Introduction  of  wire,  32 

Ligature  of  aorta,  31 

Temporary  compression  of  aorta,  32 
Abdominal  aorta,  ligature  of,  29 

Indications  for,  29 

Operation,  31 

Surgical  anatomy,  30 
Abdominal  nephrectomy,  152 
Abdominal  nephro-lithotomy,  i34    .  . 
Abdomino-peri  ureal  method  of  excision  of 

the  rectum,  515 
Abdominal  section — 

For  ligature  of  iliac  arteries,  22 

In  septic  peritonitis,  213 

In  tubercular  peritonitis,  219 
Abernethy's  incision  for  ligature  of  external 

iliac,  7 
Abscess — 

Of  kidney,  113 

In  appendicitis,  195 

Sub-phrenic,  209 
Absorbable  plates  for  enterorraphy,  248 
Acupuncture  for  abdominal  aneurysm,  32 
Acute  intestinal  obstruction,  173 

Bands  and  apertures,  179 

By  gall-stones,  186 

Intussusception,  180 
Irreducible,  183 

Operation,  174 

Question  of  operation  in,  173 

Volvulus,  185 
Acute  necrosis — 

Early  sub-periosteal  resection  in,  678 

Question  of  amputation  in,  678 
Acute  pancreatitis,  373 


Adams's  osteotomy,  722 
Albert's  method  of  gastrostomy,  302 
AUingham's  bobbin,  243 
Amputation — 

At  hip  joint  {vide  also  Hip-joint),  578 

Garden's,  625 

Chopart's,  713 

Gritti's,  627 

Hey's,  717 

Lisfranc's,  717 

Of  the  penis,  459 

Of  the  toes,  720 

At  the  metatarso-phalangeal  joints, 

720 
Through   the  phalanges  or  inter- 
phalangeal  joints,  720 

Of  the  great  toe,  720,  721 

Pirogotf's  (vide  Foot),  6gi 

Question  of,  in  acute  necrosis,  678 

Eoux's   modification  of  Syme's   {vide 
Foot),  6go 

Skey's,  717 

Stokes'  supra-condyloid,  627 

Sub-astragaloid,  695 

Syme's  {vide  Foot),  688 

Tripier's,  715 

Through  the  knee  {vide  Knee-joint), 
632 

Through  the  leg  {vide  Leg),  672 

Through  the  tarso-metatarsal  joints,  717 

Through  the  thigh  {vide  Thigh),  619 
Anal  fissure,  495 
Anal  fistula,  487 
Aneurysm — 

Aortic,  32 

Gommon  iliac,  4 

External  iliac,  10 

Femoral,  i 

Gluteal,  19,  26 


GENERAL  INDEX. 


769 


Aneurysm — 

Iliac,  29 

Inguinal,  10,  29 

Sciatic,  19 
Ankle,  erasion  of — 

Indications,  700 

Operations — 

By  transverse  incision,  700 
By  lateral  incisions,  701 
Ankle,  excision  of — 

Indications,  697 

Operations — 

By  lateral  incisions,  69S 
By  transverse  incision,  700 
Ankylosis  of  the  hip — 

Osteotomy  for,  722 
Ankylosis  of  the  knee,  637 
Anterior  tibial  artery,  ligature  of,  668 

Indications,  668 

Operations,  66g 
Anuria,  114 

Nephro-lithotomy  for,  137 
Anus,  imperforate,  517 
Aortic  aneurysm,  32 
Appendicitis,  188 

Abscess,  195 

Complications  of,  202 

Question  of  operation  in,  188 

Relapsing,  200 

Suppurative  peritonitis  in,  199 
Arteries,    ligature    of   {vide   the    separate 

Arteries) 
Arthrectomy — 

Of  ankle,  700 

Of  knee,  649 

Of  sacro-iliac  joint,  577 
Arthrodesis,  638 
Artificial  anus,  closure  of,  267 
Astragalectomy — 

For  disease,  703 

For  injury,  704 

For  talipes,  711 
Atresia  ani,  517 

Bailey's  deailcified  bone  tube,  245 
Ball's  method  of  radical  cure  of  hernia,  70 
Bands,  strangulation  by,  179 
Banks's  method  of  radical  cure  of  hernia,  71 
Barker's  method  of  gastro-jejunostomy,  329 
Barker's  method  of  radical  cure  of  hernia,  72 
Bassini's  method  of  radical  cure  of  hernia, 

63 
Bennett's  method  of  radical  cure  of  hernia, 

73 
Biliary  fistula,  369 
Biliary  tracts,  operations  on,  352 

Cholecystectomy,  368 

Cholecystenterostomy,  364 

Cholecystostomy,  354 

Cholecystotomy,  358 

Choledochotomy,  359 

Cholelithotrity,  358 

Indications,  352 

Operation,  354 
VOL.  II. 


Bishop's  method  of  radical  cure  of  hernia 

74 
Bladder — 

Aspiration  of,  431 

Complete  extirpation  of,  384 

Cystotomy,  427 

Lithotomy  {vide  Lithotomy),  391 

Lithotrity  {vide  Lithotrity),  409 

Partial  resection  of,  383 

Perinieal  lithotrity,  421 

Puncture  of,  431 

Puncture  per  rectum,  433 

Puncture  through  the  prostate,  434 

Removal  of  growths  of,  375 
Causes  of  death  after,  385 
Choice  of  operation,  378 
Complete  extirpation  for,  384 
Haemorrhage  after,  3S2 
Indications  for  operation,  377 
Operation,  379 
Partial  resection  for,  383 

Ruptured,  429 

Stone,  treatment  of,  in  children,  421 
In  the  female,  423 

Supra-pubic  puncture  of,  432 

Tubercular  disease,  operation  for,  385 
Bones  and  joints  of  the  tarsus,  excision  of, 
702 

C^CUM,  artificial  anus  in,  1 1 1 

Excision  of,  274 
Cfesarian  section — 

Abdominal  incision,  571 

Extraction  of  child,  572 

Incision  of  uterus,  571 

Indications,  570 

Operation,  571 

Sterilisation  of  patient,  572 

Time  of  operating,  570 

Uterine  sutures,  572 
Calculus — 

Renal,  114 

Ureteral,  167 

Vesical  {vide  Bladder) 
Cancer  of  uterus,  operations  for,  561 
Carden's  amputation  above  the  knee-joint, 

625 
Castration,  476 

Indications,  476 

Operations,  482 
Cholecystectomy,  368 
Cholecystenterostomy,  364 
Cholecystostomy,  354 
Cholecystotomy,  358 
Choledochotomy,  359 
Cholelithotrity,  358 
Chopart's  amputation,  713 
Circumcision,  456 

Clamp  and  cautery  operation  for  haemor- 
rhoids, 491 
Clamps,  intestinal,  259 
Cocks  operation,  440 
Colectomy,  256 
Colotouiy,  85 

49 


//' 


GENERAL  INDEX. 


Colotomy — 

By  two  stages,  97 

Causes  of  death  after,  100 

Complications  and    difficulties   in  in- 
guinal, 109 

Difficulties  in  lumbar,  98 

Indications  for,  85 

Inguinal  or  iliac,  loi 

Lumbar  or  f)osterior,  93 

Madelung's  modification  of,  107 

Of  coecuni,  1 1 1 

Of  transverse  colon,  112 

Question  of  site  of,  91 

Right  inguinal,  1 1 1 
Common  femoral  artery,  ligature  of — 

Indications,  607 

Operation,  612 
Common  iliac  artery,  ligature  of,  10 

Collateral  circulation,  15 

Indications,  10 

Operation,  16,  17,  22 

Surgical  anatomj',  14 
Congenital  dislocation  of  the  hip — 

Operative  interference  in,  604 

Results  of  operative  treatment,  606 
Comparison  of  different  methods  of  enteror- 

raphy,  253 
C'ompound  fractures,  treatment  of,  679 
Crushing  operation  for  hsemorrhoids,  492 
Cuneiform  osteotomy — 

Of  femur,  729 

Of  tibia,  728 
Cuneiform  tarsectomy  for  talipes,  711 
Cysto- colostomy,  451 
Cystotomy,  427 
C-ysts  of  the  broad  ligaments,  535 

Decalcified  bone  bobbins  — 

AUingham's,  243 

Hayes',  245 

Mayo  Robson's,  241 
Decalcified  bone  tubes — 

Bailey's,  245 

Paul's,  246 
Dislocation  of  the  hip,  operative  interfer- 
ence in,  603 
Dorsalis  pedis,  ligature  of — 

Indications,  687 

Operation,  688 
Duodenal  ulcer,  perforating,  210 
Duodenostomy,  340 

Duplay's  operation  for  hyi^ospadias,  451 
Dysmenorrhoea,  removal  of  uterine  append- 
ages for,  542 

Ectopia  vesicae,  447 

Ectopic  gestation,  operations  for,  574 

Elephantiasis,  ligature  of  external  iliac  for,  3 

Encapsuled  ovarian  cysts,  535 

Enterectomy,  256 

Eateroplasty,  279 

Enterorraphy,  227 

Absorbable  plates  for,  248 

AUingham's  bobbin  for,  243 


Enterorraphy — 

Bailey's  decalcified  bone  tube  for,  245 

By  suture,  231 

Comparison  of  different  methods  of,  253 

Hayes'  bobbin  for,  245 

Laplace's  forceps  for,  249 

Maunsell's  method  of,  233 

Mayo  Robson's  bobbin  for,  241 

Murphy's  button  for,  236 
Objections  to,  238 

Paul's  tubes  for,  246 

Vegetable  plates  for,  249 
Enterostomy,  221 
Epispadias,  455 
Excision  of — ■ 

Ankle,  697 

Astragalus,  703 

Hip-joint,  590  {vide  Hip-joint) 

Knee-joint.  634  {vide  Knee-joint) 

Os  calcis,  704 

Rectum,  498 

Tarsal  bones,  708 

Varicose  veins,  684 
Exostosis,  removal  of,  629 
External  iliac  artery,  ligature  of,  i 

Causes  of  failure  and  death,  8 

Collateral  circulation,  4 

Difficulties  and  possible  mistakes,  8 

Indications,  i 

Operation,  5,  7,  22 

Surgical  anatomy,  4 
Extirpation  of  bladder,  384 
Extra-uterine  gestation,  treatment  of,  574 

F^CAL  fistula,  closure  of,  276 
Femoral  aneurysm,  i 

Femoral  artery,   ligature    of,  in    Hunter's 
canal,  616 

Causes  of  failure  after,  619 
Indications,  616 
Operation,  618 
In  Scarpa's  triangle,  612 

Difficulties  and  mistakes,  615 
Indications,  612 
Operation,  614 
Ulceration  of  growths  into,  610 
Wounds  of,  616 
Femoral  hernia — 

Operation  for  strangulated,  35 
Radical  cure  of,  79. 
Femur — 

Osteotomy  of,  722 
Ununited  fracture  of,  630 
Fibro-cartilage  of  knee,  removal  of,  657 
Fibro -myoma  of  uterus,  removal  of  uterine 

appendages  for,  541 
Fissure  of  the  anus,  495 
Fistula  in  ano,  487 
Foot,  amputation  of,  Pirogoff's,  691 
Modifications  of,  694 
Operation,  692 
Question  of  value  of,  691 
Roux's  modification  of  Syme's  method, 
690 


(lENERAL  I^'DEX. 


771 


Foot,  amputation  of — 

Syme's  method,  688 

Causes  of  failure  after,  6go 

Sub-astragaloid,  695 
Fractures — 

Compound,  treatment  of,  679 

Simple,  operative  treatment  of,  682 

Gall-bladder  and  bile-ducts,  operations 

on,  352  {vide  also  Biliary  tracts) 
Gall-stones,  intestinal  obstruction  by,  186 
Gangrenous  hernia,  resection  of,  262 
Gant's  osteotomy,  723 
Gastrectomy,  325 
Gastric  ulcer,  perforation  of,  203 

Causes  of  failure  after  operation,  208 
Chronic  perforation,  209 
Operation — 

Cleansing  peritoneal  sac,  207 
Closure  of  ulcer,  205 
Finding  the  perforation,  204 
Subphrenic  abscess  due  to,  209 
Gastro-j  ej  unostomy — 
After-treatment,  338 
By  Laplace's  forceps,  m 
By  Murphy's  button,  330 
By  suture — 

Barker's  method,  329 
Halsted's  method,  328 
Choice  of  method,  338 
Indications,  326 
Operation,  327 
Sequelc^,  i^S 
Von  Hacker's  and  Courvoisier's  method 

of,  ii^ 
Wolflei''s  and  Kocher's  modifications  of, 

337 
Gastroplication,  339 
Gastrostomy — 

( 'auses  of  death  after,  306 

Difficulties  in,  305 

For    dilatation     of    strictures   of    the 
oesophagus,  305 

Indications  for,  296 

Operation,  299 

Abbe's  modification  of  Kaders  method, 

303 

Albert's  method,  302 

Marwedel's  method,  303 

Witzel's  method,  300 
Gastrotomy — 

For  dilatation  of  strictures  of  oesopha- 
gus, 304 

For  haemorrhage  from  gastric  ulcer,  308 

For  removal  of  foreign  bodies  in  the 

'    oesophagus,  307 

For  removal  of  foreign  bodies  from  the 
stomach,  306 
Genu  valgum,  osteotomy  for,  723 
Gluta^al  aneurysm,  19,  26 
Glutosal  artery,  ligature  of — 

Indications,  25 

Operation,  27 

Surgical  anatomy,  26 


Great  toe,  amputation  of,  720 
Gritti's  amputation,  627 
Growths  of  bladder,  removal  of,  375 
Gunshot  wounds  of  abdomen,  281 

After-treatment,  290 

Examination  of  wound,  281 

Instances  of  injuries  that  may  be  found, 
290 

Operation,  284 

Probable  amount  of  damage,  282 

Question  of  operation,  282 

Resection  of  intestine  in,  290 

Symptoms  indicating  penetration,  281 
Gunshot  wounds  of  hip-joint,  595 
Gunshot  wounds  of  knee-joint,  639 
Gunther's  modification  of  Pirogoffs  ampu- 
tation, 694 
Guthrie's  method   of  amputation    at   hip- 
joint,  586,  588 

HEMORRHOIDS,  operations  for,  489 

Acid,  492 

Clamp  and  cautery,  491 

Crushing,  492 

Indications  for,  4S9 

Ligature,  490 

Thelwell  Thomas's  method,  494 

Whitehead's  method,  493 
Halsted — 

Method  of  gastro-j  ej  unostomy,  328 

Operation  for  radical  cure  of  hernia,  75 
Hamstring  tendons,  tenotomy  of,  733 
Hayes'  bone  bobbin,  245 
Hepatic  abscess,  operation  for,  350 
Hernia,  radical  cui"e  of,  53 

Femoral,  79 

Umbilical,  82 
Hernia,  strangulated,  ^^^ 

Femoral,  35 

Inguinal,  44 

Obturator,  51 

Umbilical,  48 
Hey's  amputation,  717 
Hip-joint,  amputation  at,  57S 

Antero-internal   and    postero-external 
flaps,  589 

Antero-posterior  flaps,  5S5 

Furneaux  Jordan's  method,  579 
Operation,  584 

Lateral  flaps,  588 

Methods  of  controlling  hiemorrhage  in, 

579 
Wyeths  bloodless  method,  5S1 
Hip,    congenital   dislocation   of,   operation 

for,  604 
Hip,  dislocation  of,  operative  interference 

in,  603 
Hip -joint,  excision  of,  590 
Anterior  method,  599 
Causes  of  failure  after,  602 
Condition  of  limb  after,  593 
Conditions  of  success  in,  594 
Indications,  590 
In  gunshot  injuries,  595 


//-' 


GENEEAL  IXDEX. 


Hip-joint,  excision  of — 

Posterior  method  of,  596 

Site  of  bone  section  in,  599 
Hip-joint,  gunshot  wounds  of,  595 
Hydatids  of  liver,  treatment  of,  346 
Hydrocele,  radical  cure  of,  464 

Carbolic  acid,  465 

Iodine  injection,  464 

Partial  excision  of  sac,  467 

Operation,  469 
Hytkonephrosis,  113 
Hypospadias,  451 

Duplay's  operation  for,  451 

Eussell's  operation  for,  453 
Hysterectomy — 

For  uterine  cancer,  561 

For  uterine  myomata,  550 

Partial,  Kelly's  method,  559 

Total,  559 

Iliac  aneurysm,  4,  10,  29 

Imperfectly  develoi^ed  rectum,  517 

Imperforate  anus,  517 

Infantile  paralysis,  excision  and  arthrodesis 

for,  638 
Inguinal  aneurysm,  10,  29 
Inguinal  enterostomy,  227 
Inguinal  hernia,  operations  for  strangulated, 

44 
Inguinal  or  iliac  colotomy,  loi 
Internal  derangements  of  the  knee-joint,  657 
Internal  iliac  artery,  ligature  of — 

Collateral  circulation,  21 

Indications  for,  ig 

Operation,  22 

Surgical  anatomy,  20 
Intestinal  anastomosis,  268 

By  sutures,  269 

Murphy's  button  for,  269 

Senn's  plates  for,  271 
Intestinal  obstruction,  173 

Operation,  174 

Question  of  oj)erative  interference,  173 

Varieties,  179 

Apertures  and  slits,  180 
Bands,  179 
Gall-stones,  186 
Intussusception,  180 
Volvulus,  185 
Intestinal  sutures — 

Continuous,  228 

Czerny-Lembert,  229 

Halsted's,  229 

Lembert's,  229 
Intestine,  clamps  for,  259 
Intestine,  resection  of — 

For  gangrene,  262 

For  growths,  256 

Indications  for,  256 

Omental  grafting  in,  267 

Operation,  259 
Intestine,  rupture  of,  291 

Instances,  293 

Treatment,  293 


Intestine,  union  of  divided,  227  {vide  also 

Enterorraphy) 
Intestines,  oj^erations  on,  173 
Intussusception,  180 

Jejuxostomy,  340 

KiDKEY  and  ureter,  operations  on,  113 
Knee,  ankylosis  of,  637 
Knee-joint — 

Amputation  through,  lateral  flaps,  632 
Long  anterior  and  short  posterior 
flaps,  633 
Erasion  of,  649 

Causes  of  failure  after,  651 
Operation,  650 

Value  of,  as  compared  with  ex- 
cision, 650 
Excision  of,  634 

After-treatment,  647 

Causes  of  failure  and  death  after, 

648 
For  infantile  paralysis,  63S 
Indications,  634 
Operation,  639 
Internal  derangements  of,  657 
Removal  of  tibro- cartilage  of,  657 
Eemoval  of  loose  bodies  from,  656 
Kocher — 

Method  of  pylorectomy,  316 
Operation  for  radical  cure  of  hernia,  77 
Kraske's  method  of  excision  of  the  rectum, 
506  {vide  also  Rectum) 

Laminectomy — 

Causes  of  failure  and  death  after,  752 
For  new  growths,  750 
For  penetrating  wounds,  748 
In  cases  of  inj  ury,  746 
In  inflammatory  disease,  748 
Operation,  750 
Lane's  operation  for  talipes,  710 
Langenbiich's  incision  for  nephrectomy,  152 
Laplace's  forceps,  249,  ^^i 
Lateral  intestinal  anastomosis,  268 
Lateral  lithotomy,  391 
Le  Fort's  modification  of  Pirogofi^s  ampu- 
tation, 694 
Leg,  amputation  of — 

Lateral  skin  flaps  with  circular  division 

of  the  muscles,  672 
Teale's  method,  674 
Ligature   of    arteries    {^vide    the    separate 

Arteries) 
Ligature  for  htemorrhoids,  490 
Lisfranc's  amputation,  717 
Liston's  method  of  ami)utating  at  the  hip- 
joint,  585 
Litholapaxy  {vide  Lithotnty) 
Lithotomy — 
Lateral,  391 

Entering  the  bladder,  394 
Extracting  the  stone,  397 
Finding  the  stone,  392 


GENERAL  IXDEX. 


773 


Lithotomy,  lateral — 

Passing  the  staff,  392 
Preparatory  treatment,  392 

Median,  406 

Supra-pubic — 

Indications,  399 
Operation,  400 

Vaginal,  424 
Lithotrity,  409 

After-treatment,  419 

Choice  of  operation,  409 

Complications,  420 

Detection  of  last  fragment,  418 

In  male  children,  421 

In  the  female,  423 

Old  and  new  operations  contrasted,  419 

Operation,  413 

Perinseal  method,  421 
Liver,  abscess  of,  operation  for,  350 
Liver  and  biliary  tracts,  operations  on,  346 
Liver,  hydatids  of — 

Electrolysis  for,  349 

Enucleation  of,  349 

Incision  for,  348 

Puncture  for,  346 
Liver,   removal    of    portions   of,   for    new 

growths,  351 
Loose  bodies  in  knee-joint,  removal  of,  656 
Loreta's  method  of  dilating  the  pylorus,  310 
Lumbar  nephrectomy,  147 
Lumbar  or  posterior  colotomy,  93 
Lumbar  puncture,  752 

jNIadeluxg's  modification  of  colotomy,  107 
Macewen's   operation  for  radical   cure  of 

hernia,  64 
]\Iacewen's  osteotomy,  725 
]Male  children — 

Treatment  of  vesical  calculus  in,  421 
Marwedel's  method  of  gastrostomy,  303 
]Mannseirs  method  of  enterorraphy,  233 
]\Iaydl's  operation  for  ectopia  vesicte,  451 
]Mayo  Robson's  bone  bobbin,  241 
Median  lithotomy,  406 
Mesenteric  vessels,  thrombosis  of,  187 
j\IcBurney"s  operation  for  radical  cure  of 

hernia,  78 
]\Iickulicz's  operation  of  tarsectomy,  706 
Murphy's  button  for  enterorraphy,  etc.,  236 

Contraction  after  use  of,  238 

For  gastro-jejunostomy,  330 

For  lateral  anastomosis,  269 

In  excision  of  the  rectum,  513 

Kinking  and  strangulation  from  weight 
of,  240 

Objections  to,  238 

Obstruction  due  to,  240 

Peritonitis  due  to  slougliing  over,  239 

Sloughing  at  line  of  junction,  239 
Murphy's  drainage-tube  button,  357 
Myomatous  uterus,  removal  of,  550 

Nklaton's  operation,  227 
Nephrectomy,  140 


Nephrectomy — 

Abdominal,  152 

Causes  of  death  after,  157 

Choice  between  lumbar  and  abdominal 
156 

Combined  lumbar  and  abdominal,  155 

Indications,  140 

Langenbuch's  incision,  152 

Lumbar  operation,  147 

Partial,  158 

Results  of,  162 

Thornton's  method,  134 
Nephro-lithotomy,  114 

Abdominal,  134 

After-treatment,  128 

Causes  of  death  after,  131 

Conditions  simulating  renal  calculus, 
118 

Difficulties  in,  128 

For  suppression  of  urine,  137 

Indications,  114 

Operation,  123 

Question  of  nephrectomy  during,  130 
Nephrorraphy,  162 

Indications,  162 

Operation,  165 
Nephrotomy,  113 

Indications,  113 

Operation,  1 14 
Nerve  grafting,  738 
Nerve  stretching,  739 
Nerve  suture,  735 

Aids  in  difficult  cases,  737 

Amount  of  nerve  tissue  which  may  be 
removed,  737 

Causes  of  failure,  737 

Period  required  for  repair,  739 

Primary,  735 

Secondary,  735 

Obturator  hernia,  operation  for  strangu- 
lated, 51 
Oesophagus,  dilatation  of  strictures  of,  304, 

305 
Ogston's  osteotomy,  726 
Omental  grafting,  267 
Orchidopexy,  483 
Os  calcis,  excision  of — ■ 
Operation,  705 
Practical  remarks,  704 
Osteomalacia,  removal  of  uterine  append- 
ages for,  543 
Osteotomy,  722 

Causes  of  death  and  failure  after,  729 
Cuneiform — 

Of  femur,  729 

Of  tibia,  72S 

For  ankylosis  of  hip — 

Adams'  operation,  722 
Gant's  operation,  723 
For  genu  valgum — 

Of  shaft  of  femur,  723 
Macewen's,  725 
Ogston's,  726 


774 


GENERAL  INDEX. 


Osteotomy — 

Of  the  tibia,  727 
Ovariotomy,  526 

Accidents  during,  537 

After-treatment,  538 

Date  of  operation,  526 

Drainage,  534 

Emptying  the  cyst,  529 

Encapsuled  ovarian  cysts,  535 

Incision  for,  528 

Intra-Iigamentous  cysts,  535 

Operation,  528 

Pedicle,  treatment  of,  532 

Preparation  of  i)atient,  527 

Treatment  of  adhesions,  530 
Ovary,  operations  on,  526 

Pancreas,  operations  on,  370 

Acute  pancreatitis,  373 

Pancreatic  cysts,  treatment  of,  370 
Parker's  syndesmotomy,  731 
Partial  nephrectomy,  158 
Patella,  wiring  fractures  of,  652 

Causes  of  failure,  656 

Difficulties  in,  655 

Operation,  653 
Paid's  decalcified  bone  tube,  246 
Paul's  method  of  colectomy,  257 
Paul's  truss-pad  for  excision  of  the  rectum, 

512 
Penis,  amputation  of,  459 

Circular  method,  461 

Flap  method,  461 

Galvanic  cautery  for,  459 
Perforated  duodenal  ulcer,  210 
Perforated  gastric  ulcer,  203  {vide  Gastric 

Ulcer) 
Perforated  typhoid  ulcer,  211 
Perinseal  excision  of  the  rectum,  502 
Perineal  lithotrity,  421 
Perinseum,  treatment  of  ruptured,  521 
Peritonitis,  abdominal  section  for  septic,  213 

Tubercular,  219 
Peronteal  artery,  ligature  of,  671 
Peronsei  tendons,  di\asion  of,  733 
Phelps'  operation  for  talipes,  709 
Piles  (vide  Hiemorrhoidv) 
Pirogoffs  amputation  of  foot,  6gi 
Plantar  fascia,  division  of,  731 
Popliteal  artery,  ligature  of,  660 
Porro's  operation,  573 
Posterior  tibial  artery,  ligature  of,  663 

Indications,  663 

Operation — 

In  middle  of  leg,  667 
In  lower  third  of  leg,  667 
At  the  inner  ankle,  668 
Prolapse  of  the  rectum,  treatment  of,  496 
Prostatectomy,  388 

Choice  of  operation,  389 

Operation,  390 
Puncture  of  the  bladder,  431 
Pylorectomy,  314 

With  direct  suture  of  divided  ends,  321 


Pylorectomy — 

Combined    with    gastro  -  enterostomy, 

321 
Kocher's  method  of,  316 
With  union  of  divided  ends  by  bobbins, 
&c.,  325 
Pyloroplasty,  312 
Pylorus,  digital  dilatation  of,  310 
Pyonephrosis,  113 

Eadical  cure  of  hernia,  53 
Best  form  of  suture,  59 
Choice  of  operation,  61 
Indications  for,  60 
Justifiability  of,  54 
Methods — 

Ball's,  70 

Banks',  71 

Barker's,  72 

Bassini's,  63 

Bennett's,  73 

Bishop's,  74 

Halsted's,  75 

Kocher,  77 

Macewen's,  64 

McBurney,  78 
Need  of  wearing  a  truss  after,  57 
Of  femoral  hernia,  79 
Of  umbilical  hernia,  82 
Operation,  61 
Permanence  of  cure,  54 
Eadical  cure  of  hydrocele,  464 
Eectum,  excision  of,  498 
Abdominal  method,  515 
Abdomino-perinfeal  method,  515 
After-treatment,  516 
Amount  of  comfort  afforded  by,  500 
Causes  of  trouble  and  failure  after,  516 
Duration  of  life  after,  499 
Indications,  498 
Kraske's  operation,  506 
Management  of  defecation  after,  514 
Mortality,  499 
Murphy's  button  for,  513 
Operation,  501 
Paul's  truss  pad  for,  512 

Tube  in,  512 
Perinatal  method,  502 
Preliminary  treatment,  501 
Question  of  partial  removal,  505 
Question  of  preliminary  colotomy,  501 
Treatment   of  the  ends  of  the  bowel, 

511 
Treatment   of  the  peritoniieal   wound, 

511 

Vaginal  method,  514 
Rectum,  imperfectly  developed,  517 
Rectum,  prolapse  of,  496 

Acid  for,  496 

Cautery  for,  496 

Excision  of,  497 

Indications,  496 
Relapsing  appendicitis,  200 
Renal  calculus,  118 


GENEIJAL   IXDEX. 


//D 


Eenal  calculus — 

Conditions  simulatino-,  ii8 

Operation  for,  123 
Resection  of  intestine,  256 

Clamps  for,  259 

For  gangrene,  262 

For  growths,  256 

Indications,  256 

Omental  grafting  in,  267 

Operation,  259 
Right  inguinal  colotomy,  iii 
Roux's  amputation,  690 
Ruptured  bladder,  429 
Ruptured  intestine,  291 
Ruptured  perinteum,  521 
Ruptured  urethra,  435 
Russell's  operation  for  hypospadias,  453 

Sacro-iliac  disease,  arthrectomy  for,  577 
Sciatic  aneurysm,  19 
Sciatic  artery,  ligature  of,  2g 
Semilunar  fibro-cartilage,  removal  of,  657 
Senn's  decalcified  bone  plates,  271,  274 
Septic  peritonitis,  abdominal  section  for,  213 
Sequestrotomy,  676 

Sedillofs  modification  of  Pirogoti''s  ampu- 
tation, 694 
Simijle  fractures,  operative  treatment  of,  682 
Skey"s  amputation,  7 1 7 
Small  intestine,  drainage  of,  222 
Spina  bifida,  treatment  of,  742 

Causes  of  failure  of,  745 

Excision,  743 

Indications,  742 

Injection  with  Morton's  fluid,  742 

Simple  tapping,  743 
Spinal  anaesthesia,  752 
Spinal  theca,  tapping,  752 
Spine,  operations  on,   746  {vide  Laminec- 
tomy) 
Spleen,  excision  of,  342 

Causes  of  death,  345 

Indications,  342 

Operation,  344 
Stab,  in  mid  thigh,  treatment  of,  616 
Sterno- mastoid,  division  of,  734 
Stokes's  amputation,  627 
Strangulated  hernia,  ^^ 

Indications  for  operation,  ^^ 

Operation — 

In  femoral  hernia,  35 
In  inguinal  hernia,  44 
In  obturator  hernia,  5 1 
In  umbilical  hernia,  49 
Strictures  of  oesophagus,  dilatation  of,  304, 

305 

Strictures  of  the  ureter,  170 
Stricture-retention,  choice  of  operation  for, 

442 
Sub-astragaloid  amputation,  695 
Sub-phrenic  abscess,  209 
Superficial  femoral  artery,  ligature  of — 
In  Hunter's  canal,  616 
In  Scarpa's  triangle,  612 


Suppression  of  urine,  nephro-lithotomy  for, 

Suppurative  peritonitis  in  appendicitis,  199 
Supra-pubic  lithotomy,  399 
Sujira- vaginal  hysterectomy — 

Extra  -  peritona^al     treatment    of    the 
stump,  552 

Intra-abdominal  method,  555 
Syme's  amputation,  688 
Syme's  external  urethrotomy,  437 
Syndesmotomy,  731 

Talipes,  astragalectomy  foi-,  711 

Cuneiform  tarsectomy  for,  711 

Lane's  operation  for,  710 

Phelps'  operation  for,  709 

Removal  of  tarsal  bones  for,  708 
Tapping  the  spinal  theca,  752 
Tarsal  bones,  removal  of  for  talipes,  708 
Tarsectomy — 

Mickulicz's  operation,  706 

Watson's  operation,  707 
Tarsus,  excision  of  bones  and  joints  of,  702 
Temporary  compression  of  the  aorta,  32 
Tendo-Achillis,  tenotomy  of,  732 
Tenotomj',  730 

('auses  of  failure  after,  734 

Of  hamstrings,  733 

Of  the  peromei,  733 

Of  the  sterno-mastoid,  734 

Of  tendo-Achillis,  732 

Of  the  tibialis  anticus,  730 

Of  the  tibialis  posticus,  731 
Thelwell    Thomas's  operation  for   lui-nior- 

rhoids,  494 
Thigh,  amputation  through,  619 

Circular  method,  623 

Lateral  flaps,  624 

Mixed  antcro  posterior  flaps   and  cir- 
cular division  of  the  muscles,  620 

Practical  points,  619 

Rectangular  flaps,  624 

Transfixion  flaps,  622 
Thornton's  method  of  nephrectomy,  134 
Thrombosis  of  mesenteric  vessels,  187 
Tibialis  anticus  tendon,  division  of,  730 
Tibialis  posticus  tendon,  division  of,  731 
Tibia,  osteotomy  of,  727 
Toes,  amputation  of,  720 
Transverse  colon,  artificial  anus  in,  112 
Tripier's  amputation,  715 
Tubercular  disease    of  bladder,   operative 

treatment  of,  3S5 
Tubercular  peritonitis,  abdominal   section 

for,  2ig 
Typhoid  ulcer,  perforation  of,  211 

Ulceration    of    the    femoral    artery    by 

growths,  610 
Umbilical  hernia — 

Operation  for  strangulated,  49 
Radical  cure  of,  82 
Union  of  divided  or  injured  intestine,  227 
{vide  also  Knterorraphij) 


776 


GENERAL   INDEX. 


Ureter — 

Calculus  of,  167 

Injuries  'of,  170 

Operations  on,  167 

Stricture  of,  170 

Valvular  obstruction  of,  i6g 
Urethra,  rupture  of,  435 
Urethrotomy — 

Cock's  operation,  440 

External — 

Syme's  method,  437 
Wheelhouse's  method,  437 

Internal,  443 
Uterine  appendages,  removal  of,  539 

Conservative  surgery,  547 

Drainage  after,  546 

Enucleation  of  appendages,  545 

Haemorrhage,  546 

Indications  for,  539 

Operation,  543 

Removal  of  diseased  parts,  545 

Treatment    of    tube   when    distended, 

546 
Uterine  myomata — 

Hysterectomy  for,  559 

Removal  of,  550 

Supra- vaginal  hysterectomy  for,  552 
Uterus,  cancer  of,  oj^erations  for,  561 
Uterus,  operations  on,  550 
Ununited  fracture  of  femur,  630 

Vaginal  hysterectomy,  561 
After-treatment,  570 
Closure  of  vault  of  vagina,  568 


Vaginal  hysterectomy — 

Management  of  the  broad  ligaments,  564 

Opening  Douglas's  pouch,  564 

Operation,  563 

Preliminary  treatment,  563 

Separation  of  bladder,  563 
Vaginal  method  of  excision  of  the  rectum, 

514 
Valvular  obstruction  of  the  ureter,  167 
Varicocele — 

Excision,  472 

Indications,  472- 

Recurrence,  476 

Risks  and  causes  of  failure,  475 
Varicose  veins,  excision  of,  684 
Vasectomy,  486 

Vegetable  plates  for  enterorraphy,  249 
Vesical  calculus  {vide  Bladder) 
Vesical  growths  {vide  Bladder) 
Volvulus,  185 

Von  Hacker's  and  Courvoisier's  method  of 
gastro-jejunostomy,  336 

Watson's — 

Modification  of  Pirogoffs  amputation, 
694  _ 

Operation  of  tarsectomy,  707 
Wheelhouse's  external  urethrotomy,  437 
Whitehead's  operation  for  hfemorrhoids,  493 
Wiring  fractures  of  the  patella,  652 
Witzel's  method  of  gastrostomy,  300 
Wood's  operation  for  ectopia  vesicce,  448 
Wyeth's  bloodless  method  of  amputation  at 
the  hip-joint,  581 


End  of  Vol.  II. 


Pardon  &  Sons,  Printers,  Wine  Office  Court,  Fleet  Street,  London,  EC. 


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